Mentor Application — Diamond Footprints, Inc

Street Address

City, State, Zip

Phone Number

Creating Lasting Footprints throughout Eternity

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2017-2018 Mentor Application

“Show me a successful individual and I’ll show you someone who had real positive influences in his or her life. I don’t care what you do for a living—if you do it well I’m sure there was someone cheering you on or showing the way. A mentor.” — Denzel Washington

Name

First Name

Last Name

Email Address

Phone

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

Employer

Occupation

Are you a member of any professional, civic, or local community organizations? If so, please list them. If not, type N/A.

Have you ever served as a mentor?

Please list previous & current mentorship assignments. Include date, affiliation, etc.

Are you willing to undergo a background check?

Background check will be performed by an independent third-party entity.

Level of Education

Select ALL that apply

Have you had personal or professional experiences with disabilities that you could share with participants? If yes, please describe.

Please indicate any special interest or background in science, technology, engineering, or mathematics

Do you have any hobbies or special skills that you think will benefit mentees?

Do you speak a language other than English? If yes, please list.

Mentoring a young person is a big responsibility and can change the lives of both the Mentor and the mentee. What do you hope to gain from the experience? What do you hope the mentee will gain?

PARTICIPATION AGREEMENT

I have read and agree to the expectations listed for the Follow in my Footprints mentoring program. I authorize Diamond Footprints, Inc to contact my references and process a background check. I agree to report any past convictions to Diamond Footprints, Inc at the time of application. Further, I agree to report to Diamond Footprints, Inc any future charge or conviction at the time it occurs. I will inform Diamond footprints, Inc of any convictions or charges that relate to minors or vulnerable adults. By submitting this form, you agree to these terms.

I agree