Media Mentor Application
YES! I want to serve as a JRNOLA media mentor. Please contact me with more information on how I can be involved!
Email address *
Full Name *
Email *
I would best describe my professional media experience as:
Current or Past Employer(s) or Media Outlets *
Best Contact Phone number
Particular coverage areas of interest *
Ways you can help *
Have you ever been charged with, convicted of, or pled guilty to any crime? *If so please describe. *
Are you willing to submit to a background check as a condition of volunteering? If yes, you give permission for JRNOLA to conduct background checks on you, which may include (but are not necessarily limited to) reviews of sex offender registries, child abuse and criminal history records). I understand that false or misleading information on this application, or the discovery of inappropriate information through my background checks, may result in JRNOLA declining my mentorship application (or the termination of my mentorship position if already accepted). I hereby release and agree to hold harmless from liability to JRNOLA, the employees and volunteers thereof, or any person that may provide such information. In submitting this form I agree to my details being used for the general purpose of fulfilling my request to mentor, donate or receive an e-mail newsletter. The information will only be accessed by JRNOLA staff. I understand my data will not be distributed to third parties. I have a right to change or access my information. If you have any questions about our data security or data retention practices, please email us at I also understand that, regardless of previous appointments, JRNOLA is not obligated to appoint me to a mentorship position. If appointed, I understand that, prior to the expiration of my term, I am subject to suspension by the Staff and Board of Directors of JRNOLA for violation of JRNOLA policies. Note: JRNOLA will not discriminate against any person based on the basis of race, creed, color, national origin, marital status, gender orientation, or disability. *
For the background check, please upload a .pdf of your driver's license. *
Anything else we should know about you?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service