| Date * |
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| Applying for (check all programs that apply) * |
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| Name of Applicant * |
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| Date of Birth |
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| Address |
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| Home Telephone |
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| Cell Phone |
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| Can we communicate via text? |
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| Primary Email * |
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| Emergency Contact Name |
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| Relationship |
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| Emergency Contact Phone Number |
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| If applying to mentor, would you prefer to meet with your mentee (check all that apply) |
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| I would like to work with girls ages/grades (check) |
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| Write a brief statement on why you wish to be a mentor/facilitator in the program: |
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| Describe special interest/hobbies, which may be helpful in matching you with a mentee/workshop (e.g. cooking, crafts, career interests, chess, sports, computers, art, music, speaking another language, etc.) |
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| Residential History State the addresses where you lived for the last 10 years (beginning with the most recent) Please state the Dates you started and ended, Address, City, State, and Zip |
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| Applicant Personal/Employment History Please provide 2 personal references (other than family members). Please include Name, Relationship, Address, City, State, Zip, and Phone |
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| Applicant Personal/Employment History Employment History List the last 3 places of employment with the most recent first. Please include Company Name, Position Held, Supervisor, Full Address, Phone, and Start Date to End Date |
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| Mentor/Facilitator Release Statement I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of Eniola Sisters Enrichment and Mentoring Program. I understand and agree to the time requirements as per the job description provided for the particular role that I am applying for. Further, I understand that I will attend a training session, keep in regular contact with my mentee, and communicate with staff regularly during this period. I am willing to commit to one year in the program and then will be asked to renew for another year. I have not been convicted, within the past 10 years, of any felony or misdemeanor classified as an offense against a person or family, of public indecency, or a violation involving a state or federally controlled substance. I am not under current indictment. Further, I hereby fully release, discharge, and hold harmless Eniola Sisters Enrichment and Mentoring Program, participating organizations, and all of the foregoing employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs and expenses which may be or may at any time hereafter become attributable to my participation in the Eniola Sisters Enrichment and Mentoring Program. I understand that the Eniola Sisters Enrichment and Mentoring Program staff reserves the right to terminate a mentor from the program. The program takes place within the confines of the program’s policies and does not encourage or approve of relationships established between mentor/mentee and family members beyond the organized and supervised activities of the program. I give permission for program staff to conduct a criminal background check as part of the screening for entrance into the program. This includes verification of personal and employment references as well as a criminal check with the local authorities. Program staff has final right of acceptance of an applicant into the program and reserves the right to terminate a mentor from the program at any time. I have read the above Release Statement and agree to the contents. I certify that all statements in this application are true and accurate. Please Input your initials in the box on the right. * |
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Match the number shown on the left |
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