* 1. Name of Applicant:

* 2. Nickname (if any):

* 3. Gender:

* 4. Date of Birth:

* 5. Address:

* 6. Home Phone:

* 7. Cell Phone:

* 8. Email:

* 9. Preferred method of contact:

* 10. T-Shirt Size (Adult):

* 11. What is you Race/Ethnicity?

* 12. Are you employed?

* 13. If employed, what company do you work for and what is your title?

* 14. Are you currently enrolled in school?

* 15. If in school, where do you attend and what is your major?

* 16. What languages (other than English) do you know?

* 17. Highest level of education you have completed:

* 18. Camp Mariposa location:

* 19. How did you hear about the Camp Mariposa program?

* 20. Briefly describe why do you want to be a mentor with the Camp Mariposa program?

* 21. Are there any conflicts or constraints that might make it challenging for you to participate in the program?

* 22. Do you have any previous experience with youth who are at risk?

* 23. If yes, please provide a brief description of your experience.

* 24. Do you have any personal or professional experience working with adults/youth/families impacted by substance abuse or addiction?

* 25. Any special skills we should know about?

* 26. Have you ever been convicted of a crime?

* 27. If yes, please explain below.

* 28. Have you ever been interviewed by Child Protective Services (CPS)?

* 29. If yes, please explain below.

* 30. Camp Mariposa requires at least two references for all mentors. One of the references must be a professional reference. Please feel free to provide any additional references to help us ensure the completion of your application in a timely manner.
Please include the following: Name, relationship, years known, telephone number, email, physical address, and preferred method of contact.

Reference 1:

* 31. Reference 2:

* 32. Reference 3:

* 33. Reference 4:

* 34. I hereby certify that the information given on this form is factual and complete. I give my permission for any necessary verification. I release from liability any person and/or this organization giving, receiving, or utilizing any such information in making decisions regarding my application to volunteer. 

* 35. E-Signature

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