Volunteer & Mentor Application Form

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We sincerely appreciate your dedication in contributing your time and efforts as a volunteer/mentor with Break The Cycle Today. Kindly take a few moments to complete this form. Rest assured that all information you furnish will be treated with utmost confidentiality.

By submitting this form, you acknowledge that volunteers/mentors generously contribute their time to engage in community service without financial compensation.

Email *

Full Name *

Phone Number *

Home Address *

Gender *

Male

Female

Date of Birth *

YYYY

Social Security Number *

Ethnicity *

Asian

African American

American Indian/Alaska Native

Caucasian

Native Hawaiian/Other Pacific Islander

Hispanic

Other:

Education Level (Highest Degree Completed) *

Emergency Contact - Full Name *

Emergency Contact - Phone number *

Emergency contact - Relationship *

Volunteer Availability (Check all that apply) *

Weekday - Morning

Weekday - Afternoon

Weekday - Evening

Weekend - Morning

Weekend - Afternoon

Weekend - Evening

Required

Relevant Training/Experience (N/A if not applicable) *

List of volunteer history (N/A if not applicable) *

1 - 3 references. Please include: references name, phone number, and email address *

Age preference for your mentee

What do you hope to gain from being a mentor?

What other skills, or activities you have that would benefit the youth?

How did you hear about Break The Cycle Today

Send me a copy of my responses.

Submit

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