Wufoo

Date * MM / DD / YYYY
Name * First Last
Birthday * MM / DD / YYYY
Email *
Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Number * ### - ### - ####
School or Business Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
School or Business
Phone Number ### - ### - ####
Fax ### - ### - ####
Occupation *
I would prefer to receive my Girls Inc. correspondence in: *
I would prefer to receive Girls Inc. communication via: *
Please call me at: *
Home Business
Best time to reach me: *
Transportation: *
Auto Insurance Company:
Auto Insurance Policy #:
What languages do you speak fluently? *
How much time each week will you commit to your mentee? *
1-2 hours 2-3 hours 3-4 hours More than 4 hours
Do you foresee any period during the year in which you will be unable to meet with your mentee for more than two weeks? *
No Yes, please indicate when:
What are the best days and times to meet with your mentee? *
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What are the best times for you to meet with your mentee? *

Please indicate what times will generally work for you to meet with your mentee.
What experience have you had with mentoring and volunteering with youth? *
Why are you interested in being a mentor?
Why do you think you would be a good mentor? *
List at least four words that you would use to describe yourself: *
What do you like to do in your free time? *
Character reference #1
Name * First Last
Character Reference #1 Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Character Reference #1
Email *

Please provide three character references. You may use friends, teachers, supervisors or clergy members. Please do not include family members.
Character Reference #1
Phone Number * ### - ### - ####
Character reference #2
Name * First Last
Character Reference #2 Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Character Reference #2
Email *
Character Reference #2
Phone Number * ### - ### - ####
Character reference #3
Name * First Last
Character Reference #3 Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Character Reference #3
Email *
Character Reference #3
Phone Number * ### - ### - ####
Optional Information:

How do you describe your race and ethnicity? Feel free to check more than one box.
Asian/Pacific Islander African-American Latino/Hispanic Caucasion Native American Southeast Asian Other
Do you have a preference about your mentee's ethnic/racial background?
I would like to be matched wtih a girl who is the same race as me. I would like to be matched with a girl who is a different race as me. No preference.

Optional
Do you have a religious affiliation? If yes, please describe.

Optional
Optional:

Is it important to you to be matched with a mentee who shares your religious background?
I would like to be matched with a girl who shares my religious beliefs. I would like to be matched with a girl who has a different race. No preference.
How did you hear about the mentor program? *
Friend TV ad At work Mentee Poster Radio ad At church Girls Inc. staff Other

Optional
Do Not Fill This Out