2010-11 Mentor Application (rev June. 2010)
Preuss School UCSD
MENTORSHIP APPLICATION
Name______Today’s Date______
Organization______Work Phone______
Home Address______Home Phone______
City, St., Zip______Age: _____ Sex: M F
Ethnicity Email address
Please choose your career fields or interests by marking 1 through 4 for choices:
____Science____English____Computers
____Business____Art____Medical Fields
____Environment____Music____Government
____Mathematics____History____Other
Educational Background ______
Previous experiences with youth______
(Scouts , church, community)
______
Have you ever been a mentor? YesNo
If so, please describe your experience.
Please circle any of the activities below that interest you. List others in the blank spaces.
BasketballFootballDanceMartial ArtsGamesCars
BaseballCampingHikingFashionCookingGolf
MusicShoppingArtTravelOther:
Personal References:______
NamePhone
Address
______
NamePhone
Address
MENTORSHIP APPLICATION
1. The preferred gender of your mentee:MaleFemale
2. The preferred age of your mentee (11-17 years of age)
3. Specific day and time frame you are available:
4. Why are you interested in becoming a PreussSchool mentor?
5. Please describe your hobbies and interests:
6. Please describe your occupation:
7. What support or training do you think you will need to be a successful mentor?
8. Describe the kind of student with whom you would like to be matched.
9. How did you hear about the program?
THANK YOU !
Preuss School UCSD
MENTORSHIP APPLICATION
This information ensures that all persons at our school site can be identified at all times.
Soc. Sec. No. Driver’s Lic. DOB:
Height: Weight: Eyes: Hair: Sex:MF
Notify in case of emergency: (Name) (Phone)
Signature: Date:
All volunteers are required to provide proof of satisfactory tuberculosis screening conducted within 60 days of the date of this application.
Additionally, if transporting student(s) in privately owned vehicle, the volunteer must provide a copy of a current driver’s license and proof of insurance ($100,000/$300,000)
Do you have any criminal charges pending against you?___ Yes___ No
Have you ever been convicted of a felony?___ Yes___ No
Have you ever been convicted of a sex or drug related offense? ___ Yes___ No
Are you required to register as a sex offender under Penal Code 290.95? ___ Yes___ No
If yes to any of the above, please describe:
For security reasons, a criminal history check will be made; a check against the Megan’s Law records will be completed; and references will be checked. You may not mentor if you have been convicted of a felony or are required to register as a sex offender under California Law. Also, mentor assignments are subject to our school’s needs and may be terminated if service is unsatisfactory. I give permission to have my personal and professional references researched, understand a criminal records check is required/will be conducted, and hold the Preuss School UCSD and any individuals providing the school with information harmless. By signing my name below, I declare under penalty of perjury, that all the information on this application is true and correct.
I, , authorize Preuss School UCSD to conduct a (Name)
background check.
Signature:Date:
PLEASE RETURN THIS FORM TO:
The Preuss School UCSD
9500 Gilman Dr.
La Jolla, CA 92093-0536