I'd Like to Mentor or Volunteer

I'd Like to Mentor for Micah's House NWA
You will be contacted after we review your application.

Please note: Mentors will be asked to agree to a background check.
Full Name*

First NameLast Name
E-mail*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please list all members of your household: Name, Sex, Age, Relationship to Applicant
Primary Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Employment
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
Supervisor's Phone Number

Area CodePhone Number
Dates of Employment

MonthDayYear
Start Date
MonthDayYear
End Date (or today's date if you are currently employed)
Position Held
Mentor Interests

Please complete the following survey. Your answers will help Micah's House know more about you and provide a good match for you.
What are the most convenient times for you to meet with your mentee? Please check all that apply.

WeekdaysWeekendsLunchtimeAfter SchoolEveningsOther
Please indicate the age(s) you are interested in working with:

18-1920-2121-26
Do you speak any languages other than English? If so, which languages?
Hobbies & Interests
Describe your ideal Saturday
I will provide my consent for a background check*

YesNo
I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.*

I agree
I understand that Micah's House M68 Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.*

I agree
I agree to allow Micah's House to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotional or marketing materials.*

I agreeI do not agree
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.*
Signature
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I'd Like to Mentor for Micah's House NWA

Mentor Interests