Mentor Application - Everybody Wins! DC

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Part 1: Contact Information

* Name:

First: MI Last

* Sex:

M F

Job Title:

* Company/Organization:

Congressional Office:

* Work Street Address:

* Work City:

* Work State:

* Work Zip:

* Work Phone:

Ext.

Work Fax:

Cell:

(in case we need to reach you when you're out of the office)

* Home Street Address:

* Home City:

* Home State:

* Home Zip:

* Email:

* Birth Date:

Ethnicity:
(Optional)

African-American or Black	Hispanic
American Indian	Pacific Islander
Asian	Other:
Caucasian

Supervisor's Name:

Supervisor's Phone:

Ext.

* Non-work
Reference's Name:

* Non-work
Reference's Phone:

Ext.

Part 2: Program Preferences

* School Assignment:

* Were you in the program last year?

Yes No

If yes, date you began mentoring with EW!DC:

If yes, name of student:

Would you like to continue
with this student?

Yes No

* Days of the week
you are available

Mon Tue Wed Thu Fri

* Preferred
sex of student:

Male Female No Preference

* Preferred grade
level of student:

1 2 3 4 5 6 No Preference

Other languages spoken:

Two volunteers from the same organization may share a student partner. The alternate must also complete an application. If you would like to alternate with a partner, but don’t know of someone, EW! may be able to help you find someone.

Do you want to alternate with another volunteer?

Yes No

If yes, name of partner:

Questions/Comments: