General Applicant Information ( * denotes required questions)
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First Name:*
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Last Name:*
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Street Address:*
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City:*
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State:*
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Zip Code*
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Phone Number:*
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Email:*
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Birthdate: xx/xx/xxxx*
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Gender:*
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Male
Female
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If relevant, what college did you attend?
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If relevant, what's your major?
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If relevant, what is your occupation?
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What other commitments do you have during an average week?
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Do you have access to transportation to and from Open Door?*
Yes
No
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Emergency Contact Information: Name, Address, Phone #
Reference (1 of 2): Name, Address, Phone #, Relationship to Applicant
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Reference (2 of 2): Name, Address, Phone #, Relationship to Applicant
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interest in program
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Do you have any previous experience with middle/high school students? If so, please
describe.
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What do you see as the role of a mentor?
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Why do you want to participate as a mentor?
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Have you ever been abused (e.g. sexually, physically, verbally)?*
No
Yes
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If yes, please comment on your recovery process.
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Have you ever been accused (rightly or wrongly) or investigated for sexual improprieties
with a minor?*
No
Yes
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Questions / Concerns?
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matching information
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In order to help ensure that mentors and students are matched successfully, there
is some additional information to provide. There is no wrong answer. We will be
using the information in the beginning of the matching process, but students and
mentors will meet and interact before a match is made.
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Where did you grow up?
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Who did you live with growing up?
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What is your current living situation?
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What words describe your middle school experience? (select all that apply)
Fun
Lonely
Awkward
Stressful
Friends
Dating
Rebellious
Other:
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What words describe your high school experience? (select all that apply)
Fun
Lonely
Awkward
Stressful
Friends
Dating
Rebellious
Other:
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What words describe your family relationships during middle/high school? (select
all that apply)
Conflict
Loving
Alone
Support
Pressure
Fun
Other:
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What activities/sports did you participate in during middle/high school (select
all that apply)
Theater
Band
Orchestra
Football
Hockey
Baseball
Soccer
Tennis
Lacrosse
Track
Cross Country
Voice Lessons
Dance
Gymnastics
Choir
Swimming
Student Council
School Newspaper
Volleyball
Basketball
Other:
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What is your favorite TV show?
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What is your favorite band?
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What things do you enjoy in your free time?
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