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Name:*
Address:*

Availability

(Check all boxes that apply.)

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:

Education

Please check:*
Other - please explain:

Job Experience

Current Employer:*
Position/Title:*
Job duties:*
Date of hire:*

Community Experience

Are you involved in any organizations, clubs or volunteer positions in the community? If yes, please elaborate:*
What would make you a good mentor? :*


Have you ever been convicted of a felony? If yes, please explain:*

Signature (typing your name here serves as your electronic signature) :*
Phone:*
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E-mail (if none enter N/A):*
Date:

(Note: After clicking on "Submit" below you will need to come to the ROE 41 office (157 N. Main St., Edwardsville, IL  62025) to be fingerprinted and have a background check.)

How did you hear about Give 30?:
Office Use - Fingerprints Cleared? (For Office Use Only):