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Mentoring Application

Basic Information
How did you find out about mentoring?*  Other:
Mentor Information
Name*   
Social Security (Last 4 Digits)* 
Date of Birth*     
Contact Information
Street Address 
City, State, Zip     
Preferred Phone Number*   
E-Mail Address* 
Confirm E-Mail Address*   
General Information
Gender 
Marital Status
Ethnicity
Highest Level of Education Completed 
Age Group Preference
Have you ever mentored before?  Where?
Which vicinity do you prefer to mentor a student?
How many miles are you willing to travel?
Special skills, languages or hobbies*
Employment Information
   
Employers Name
Street Address
City, State, Zip ,
Employer Phone
What is your current occupation?
Employers Email Address
   
   
References
Name of Reference (1)
Street Address
City, State, Zip ,
Phone
Email Address (optional)
   
Name of Reference (2)
Street Address
City, State, Zip ,
Phone
Email Address (optional)
   
Name of Reference (3)*
Street Address
City, State, Zip ,
Phone
Email Address (optional)
   
Authorization & Consent
Have you ever been convicted, pled no contest, or had adjudication withheld in a criminal offense, felony, misdemeanor or are there any criminal charges now pending against you other than a minor traffic violation?
   
Would you agree to an employer/criminal background check?
   
I understand that I am offering my services to the Hillsborough County Public School System without compensation. I certify that all information given on this application is true and complete. Any misrepresentation, omission or incorrect statement of facts called for in this application is cause for immediate dismissal of me as a volunteer. I agree, if I am a volunteer, to abide by all school board rules, regulations and policies, either published or in effect by usage and all rules, regulations and laws of the State of Florida as may be required by Florida Statues and the School Board of Hillsborough County.