CommUNITY Mentoring Program- Mentor Interest Form
Thank you for your interest in becoming a mentor to Queen Anne's County youth. CommUNITY Mentoring serves students in 7-12th grades at risk of disconnection and youth ages, 16-24 not attending school nor working. In addition to quality mentoring, our program provides workshops, field trips, and homework help. Mentors agree to meet with their mentee(s) for at least one hour, once per week, for a year.
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E-mail *
Your Email
Your Name *
Date of Application *
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Date of Birth *
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Address
Race *
Gender *
Occupation/Employer
Personal Phone/Email *
Work Phone/Email
Reason for your interest in becoming a mentor: *
What days of the week can you participate? (Check all that apply.)
What times are best for you? (Check all that apply)
Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency, or a violation involving a state/federally controlled substance? *
Consent: By signing below, you are granting permission to the Program Coordinator of CommUNITY Mentoring to conduct a background check including but not limited to reviewing your criminal and driving records, social media profiles, and other relevant information. *
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