PEAK Mentor Application
PEAK relies on the generous support of many volunteers to carry out its mission of providing opportunities for underserved youth. We recognize the private nature of the information contained herein and as such, will treat it as confidential.
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Basic Information
First and Last Name *
Birthday
MM
/
DD
/
YYYY
Current Address *
Cell Phone *
Work Phone
May we contact you at work? *
I am interested in *
Required
Current place of employment, title, date you began this position *
Preferred Email *
Secondary email
How did you hear about PEAK? *
Educational History
Please list your educational history, starting with the most recent (school name, dates attended, name of program/degree, completed y/n). *
Interests and Activities
What has been your past volunteer experience? *
Why are you interested in volunteering with high school students? *
Why do you believe you would make a good PEAK mentor? *
What are your hobbies and interests? Are you involved in any clubs or groups? *
Do you have experience with any languages other than English? If yes, which language and what level?
Describe any special skills, training, or certification that you have.
Have you received any awards or special recognition for your work, philanthropic or volunteer interests?
How would you describe yourself, or how would your close friends describe you? *
Is there anything else we should know about you or your background that would help us match you with a scholar?
Would you like to learn more about getting involved with PEAK in other ways? If so, please indicate areas of interest:
Contacts and References
Please provide at least two professional and one personal reference (none of whom should be a relative) and include: name, phone, email, relationship, and how long they have known you
Professional Reference 1 *
Professional Reference 2
Personal Reference *
Emergency Contact (name, phone, email, relationship) *
Personal History
Please note: for any items that you check "yes," please explain in greater detail at the end of this application
Have you ever been convicted of a criminal offense (felony or misdemeanor, other than minor traffic offenses)? Answer "yes" if you have entered a plea agreement including a deferred sentence or deferred judgment arrangement in connection with a criminal case. *
Have you ever been charged with a sexual offense, offense relating to children or minors, or crime of violence? *
Have you ever been the subject of a civil lawsuit involving sexual misconduct, violence, or injury involving children or adults? *
Have you ever been reported to any organization or registry for abuse or misconduct involving children or adults? *
Do you have any disciplinary action or investigation pending by an employer, other organization, professional association, or licensing body for violence, sexual misconduct, or misconduct involving children? *
Have you ever been disciplined or dismissed from any volunteer position or employment following an allegation of sexual misconduct, physical aggression, verbal aggression, or other inappropriate behavior or conduct? *
Have you ever been reprimanded or asked to leave or end your membership in a volunteer, civic, or non-profit organization? *
Have you ever been the subject of a complaint or disciplinary proceeding brought against any professional license or professional affiliation held by you? *
Have you changed your name in the last 7 years? If so, what was your previous name?
Additional explanations:
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