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
Preferred Method of Communication
Home Phone Cell Phone
Work Phone Email
* Date of Birth
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Marital Status
Household Income
Spouse First Name
Spouse Last Name
Spouse Prefix
Military Service
Owns a Firearm
Tobacco, Alcohol, and Drug Use Histroy
Motivational Factors
Demographic Information
* Gender
Primary Language
Secondary Language
Secondary Language Other
Type of Disability
Type of Disability Other
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
Own Car
Drivers License
Drivers License State
Drivers License Number
Drivers License Issue Date
Drivers License Expiration
Public Transit Available
Public Transit
Career Focused Interests
Career Focused Interests Comments
Mentor Preferences for Match
Age Range
Willing to be matched with mentee from home with a history of
School Name
Education Level
Year Degree Attained
Date Expressed Interest
Recruitment Source
Document 1
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Document Type 1
Document Type 1 Other
Document 2
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Document Type 2
Document Type 2 Other
Program Questions
* Residing Community
* How did you learn about CME?
* What clubs or groups, if any, do you belong to?
My favorite subject in school was:
* My least favorite subject in school:
* What qualities would you like in a mentee?
* What individual has served as a role model for you? Why?
* If you could recommend one book for your mentee to read, what would it be?
* Have you ever been arrested for and/or convicted of any felony or misdemeanor other than a minor traffic violation? If yes, please explain:
* Are you under current indictment or have a district/county attorney accepted an official complaint for any felony or misdemeanor against you? If yes, please explain:
* What would you like to do with a mentee?
* What characteristics do you believe a good mentor should possess?
* In addition to participating in CME workshops, attending CME sponsored events, and communicating regularly with the mentees, what other ways are you willing to be of assistance?
* Have you previously mentored a youth or teen through a formal program or worked with youth in another volunteer capacity? Yes No If yes, what was the name of the organization or program?
* What do you feel are strengths you can bring to this program?
* Will you agree to have College Mentoring Experience check your background through federal and state agencies for criminal records and child abuse and neglect proceedings?
* Have you ever been accused of child abuse? If yes, explain:
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