Application

Thank you for agreeing to be a mentor in the Bright S.T.A.R. Mentor Program.  Please complete the application. Since the program has an established schedule you can disregard the section on "Availability".  If you have any questions, please contact me.  

Thanks, 

Maria Campbell

Director of Advancement

614-893-7150

mcampbell@brightwaycenter.org

Basic Information
* First Name
Middle Name
* Last Name
Email Address
Contact Information
Home Address 1
Home Address 2
Home City
Home State
Home Zip Code
Home Phone
Mobile Phone
Work phone
Demographic Information
* Gender
Other
Availability
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
Program Questions
* Birth Date (needed for record checks)
* Ethnicity
* Educational Background
* Preferred method of communication:
* Within the past 10 years, have you been convicted of any felony or misdemeanor classified as as offense against a person or family, or an offense of public indecency or a vilation involving a state federally controlled substance?
* Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in the previous question. +
If the answer is YES to question 1or 2, please explain below.
* Provide the name, address, city, state, zip, phone number and relationship of 4 references. Please include at least one friend, work & family member.
Electronic Signature
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In signing this application to be a mentor, I understand that Brightway Center routinely performs criminal record checks of all volunteers.  My signature authorizes this check be done on me.  
I certify to the best of my ability that the information provided on this application is true and accurate.  I also understand that misinformation knowingly provided here, and on subsequent mentor application forms, is grounds for dismissal.