Basic Information
* First 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
Preferred Method of Communication
Home PhoneCell Phone
Work PhoneEmail
* Date of Birth
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Marital Status
Spouse First Name
Spouse Last Name
Spouse Prefix
Military Service
Tobacco, Alcohol, and Drug Use Histroy
Motivational Factors
Motivational Factors Other
Demographic Information
* Gender
Sexual Orientation
Primary Language
Secondary Language
Secondary Language Other
Primary Religion
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
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 Type 1
Document 1
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Document Type 2
Document 2
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Electronic Signature
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Please Read Before Signing:

Marathon Scholars does not discriminate according to race, religion, physical disability, or sexual or gender identity or preference.


I hereby apply for membership as a Coach with Marathon Scholars. I understand that Marathon will interview me about my background, motivation, expectations, and other personal qualities that are relevant to my potential role the organization. I agree to supply Marathon Scholars with proof of my automobile insurance and it is attached above as Document 1. I agree to supply Marathon Scholars with a list of four references including 1 relative, 1 coworker, and 2 friends I've known for at least 2 years attached as document 2. I understand Marathon Scholars will review references and investigate any and all facts concerning my qualifications for becoming a Coach. I certify that all information provided by me in this application is complete, true, and accurate. I acknowledge that intentional omission or falsification of information will be cause for refusal of placement or immediate dismissal at any time during the period of my placement.


I understand that Marathon Scholars must prioritize the best interests of the Scholars at all times.

By completing this application, I understand that I am not obligated to accept nomination as a Marathon Coach. I further understand that Marathon Scholars is not obligated to accept my application as a Marathon Coach.

I understand that the statements I make to the staff of the agency will be held confidential within Marathon Scholars, unless disclosure is required by law. Specifically, I understand that incidents of child abuse or molestation, past or present, or threat of harm to oneself or others are issues that must be reported to proper authorities.  I understand that certain information about me will be discussed with the parent(s)/guardian(s) of the child with whom I am matched. If there is information that I do not want repeated, it is my responsibility to discuss this with Marathon Scholars Staff.


I agree to notify Marathon Scholars immediately of any changes in the information provided in this application.