A.C.T., Inc. MENTOR APPLICATION         Make a difference, sign up today.

(Instructions: To sign up as a mentor, print out this form and complete it as accurately as possible. Please print clearly. When completed, just mail it to: Adults Caring for Teens, P.O. Box 354, Nyack, NY 10960. You can also fax it to (845) 358-1877.) An A.C.T. staff person will review it and contact you as soon as possible.

Personal Information:
Male___    Female___
First Name ____________________ Middle Initial ___  Last Name _________________________
Address
Street __________________________ City____________ State __ Zip __________
Home phone:______________________   Mobile Phone: ________________________
Name/address of employer ______________________________________
Your Work Phone ________________________    Occupation ______________________
E-mail Address_________________________________
 

Volunteer Information
1. Indicate your grade preference: __Elementary     __Jr. High/Middle School    __High School _

2. What do you think are the strengths (bilingual, math skills, previous relevant volunteer experience, etc.) you can bring to this program?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

3. Write a brief statement on why you have chosen to participate in the mentor program.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

4. Initial the two statements below.

_____I understand that the mentor program involves spending a minimum of one hour every week for the academic year at a school with an assigned student.

_____I understand that I will be required to complete the mentor program orientation and at least two training sessions during the year.
 

References
1. Please list at least three references (please include at least one family member, one personal friend, and one work reference):

Name _________________________           
Address _________________________         Address ____________________________
City ______________State__ Zip_____       
Phone number ________________              
Relationship ________________                 

Name _________________________           
Address _________________________         Address ____________________________
City ______________State__ Zip_____       
Phone number ________________              
Relationship ________________

Name _________________________           
Address _________________________         Address ____________________________
City ______________State__ Zip_____       
Phone number ________________              
Relationship ________________ 

Name _________________________           
Address _________________________         Address ____________________________
City ______________State__ Zip_____       
Phone number ________________              
Relationship ________________                

In making this application to be a volunteer, I understand that A.C.T., Inc. -Adults Caring for Teens routinely performs criminal and driving record checks of all volunteers for the position of mentor for which I am applying. This check may be done on me if I sign below. If I fail to sign, it may be grounds for rejecting me as a mentor.

I certify to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and on subsequent mentor application forms, is grounds for dismissal.

______________________________                        ___________________________
        Signature                                                                                       Date

Thank you for completing the form. To send it, follow the instructions at the top of the page.