First Name *

Last Name *

Address *

Email Address *

Home Phone Number *

Cell Phone Number *

Date of Birth *

Male or Female *

Gender *

How did you hear about the ICA Mentoring Program? *

What is the highlest level of education achieved?

Are you currently employed? *

Name your employer *

What is your job title? *

How would you describe yourself as a person? *

List at list four hobbies or interests: *

Do you have experience working with teenagers? *

Describe why you would like to become a mentor *

Have you ever applied to be or have been a mentor with ICA? *

If yes, when?

Can you commit the summer to being a mentor if selected? *

What are the most convenient times for you to meet with your mentee? *

Please list any other community or professional groups you are affiliated with: *

Have you ever been convicted or investigated for any crimes? *

I understand that the Youth Leadership Program features special events, activities and programming all related to the environment. Media representatives, newspaper and television reporters, photographers, and public relations personnel may be present at some special events to document their work. In some cases they may be interview and/or photograph mentors who participate in these events. These photographs, videos, and interviews will only be used to display the efforts of the Youth Leadership Program. I give permission to be photographed or otherwise recorded during these events and activities, and for any and all such photographs to be displayed by ICA and its subsidiary programs (i.e. Youth Leadership Program), whether now or hereafter known or developed. *

This application will be complete upon submitting an updated resume and 3 references: each should know you for at least 1 year (one professional) to Padma@indocaribbean.org *

Pursuant to the Federal Privacy Act (PL 93-579) and the Information Practices Act of 1977 (Civil Code Section 1798, et seq.), notice is hereby given for the request of personal information by this form. The required personal information is voluntary. The principal purpose of the voluntary information is to facilitate the process of this application. The failure to provide all or any part of the requested information may result in the inability to process your application. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular.