Name:*
Address:*

Availability

(Check all boxes that apply.)

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:

Please indicate which school district you would prefer (this doesn't ensure you will be placed in that district.)

Please choose:

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 explain:*
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:*
-
E-mail (if none enter N/A):*
Date:

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

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