Application

Thank you for your interest in becoming a mentor in the Mt. Stuart After School Program.  Please fill out this application to the best of your ability. Don't hesitate to call and ask questions. Upon completion our program coordinator will you give you a call to fill you in on the details of the program.

Youth Services Mentor Program

509-962-2737

Basic Information
Prefix
* First Name
Middle Name
* Last Name
Email Address
Password
Confirm Password
Contact Information
Home Address 1
Home Address 2
Home City
Home State
Home Zip Code
Home Phone
Mobile Phone
Work phone
Work phone ext.
Preferred Method of Communication
Home Phone Cell Phone
Work Phone Email
Social Media
Facebook
Twitter
Website
Basic
* Date of Birth
Photo
No file is currently uploaded.
Upload File
Marital Status
Spouse First Name
Spouse Last Name
Military Service
Owns a Firearm
Tobacco, Alcohol, and Drug Use Histroy
Motivational Factors
Motivational Factors Other
Demographic Information
* Gender
Sexual Orientation
Primary Language
Other
Secondary Language
Secondary Language Other
Ethnicity
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
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
Start Date
End Date
Year Degree Attained
Major
Referral
Date Expressed Interest
Recruitment Source
Target Audience
Motivation
Documents
Document 1
No file is currently uploaded.
Upload File
Document Type 1
Document Type 1 Other
Document 2
No file is currently uploaded.
Upload File
Document Type 2
Document Type 2 Other
Program Questions
* Social Security Number
* Personal Reference 1 Name
Personal Reference 1 Email
* Reference 1 Phone Number
* Professional Reference 1 Name
Professional Reference 1 Email
* Professional Reference 1 Phone
* Mentor Application
Electronic Signature
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This electronic signature verifies you are interested in becoming a mentor, thank you so much.