Application

Basic Information
Prefix
* 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 PhoneCell Phone
Work PhoneEmail
Basic
* Date of Birth
Photo
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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
Other
Secondary Language
Secondary Language Other
Ethnicity
Other
Other
Disability
Type of Disability
Type of Disability Other
Availability
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
Transportation
Own Car
Drivers License
Drivers License State
Drivers License Number
Drivers License Issue Date
Drivers License Expiration
Public Transit Available
Public Transit
Interests
Skills/Interests
Career Focused Interests
Career Focused Interests Comments
Mentor Preferences for Match
Age Range
Race
Willing to be matched with mentee from home with a history of
Education
School Name
Education Level
Other
Year Degree Attained
Major
Referral
Date Expressed Interest
Recruitment Source
Motivation
Documents
Document Type 1
Document 1
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Document Type 2
Document 2
No file is currently uploaded.
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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 has 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?
* How did you learn about CME?
* Why would you like to be a CME Mentor?
* 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:
Electronic Signature
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