Mentor Application
Thank you for your interest in becoming a C4K mentor! We look forward to connecting with you!
First Name *
Your answer
Middle Name
Your answer
Last Name *
Your answer
Name You Prefer
Your answer
Gender *
Racial or Ethnic Group *
Birthdate *
MM
/
DD
/
YYYY
Employer
Your answer
Are you an UVA student? *
If yes, what is your anticipated graduation date?
Your answer
Contact Information
UVA Students: Please list your permanent mailing address.
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone *
Your answer
Textable? *
Email Address *
Your answer
Preferred method of contact *
Emergency Contact *
Name, Phone Number, Relationship
Your answer
How did you hear about C4K? *
Your answer
Authorization
I hereby authorize Computers4Kids (C4K) to make an independent investigation of my background, references, character, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for serving as a volunteer working with children in the programs administered by C4K.

I release Computers4Kids and any person or entity which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regard to the information obtained from any and all of the above referenced sources.

I certify that the following is my true and legal name and that all information contained herein is true and correct to the best of my knowledge.

Authorization *
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