ASPIRA / SPRINT Mobile Mentorship Program Form

ASPIRA of Florida

ASPIRA / SPRINT Mobile Mentorship Program Form

MENTORSHIP COMMITMENT

Mentors will commit to at least one interaction with mentee per semester for the 2016-2017 school year outlining short term and long term goals.
Mentors will commit to being available for school,career,and mentorship coaching via text at least once a month for the duration of school year.
Mentors will commit to meeting with mentee and doing a mid-semester and end-of-semester evaluation form detailing accomplishments and new goals.

* Required information.

For submitting your data don't fill this following email field:

Application Date *

* I acknowledge that I understand my Social Security Number will be collected for the use of state mandated background checks only . *

Name *

Home Address *

City, State and Zip Code *

Home Phone

Work Phone *

Cell Phone *

E-mail Address *

Gender

Male

Female

Ethnicity

Date of Birth *

Emergency Contact's Name *

Emergency Contact # *

Current Employer /Organization/Affiliation *

Dates Employed *

Past employers/Organizations/Affiliations

Dates Employed

Are you bilingual? *

Primary Language

English

Spanish

Other

Are you a parent/guardian/family member of (a) student(s) ? *

If you are an ASPIRA/SPRINT employee please provide your employee number

Are you an active or former member of law enforcement, a firefighter, a Department of Children & Family Services employee, a judge, a state or assistant attorney, a prosecutor, a government employee with duties involving human resources, labor relations, code enforcement officers or a spouse or child of the foregoing categories? *

Have you ever entered a plea of Nolo Contendere (no contest), a plea of Guilty, been placed in pre - trial intervention program or on probation, or been fined in a criminal proceeding? *

Have you ever received an adjudication of guilt, had adjudication withheld, had a criminal case result in a nolle prosequi ("nol pros"), or had a criminal record sealed or expunged? *

Please rank from 1 to 7 ( 1 being the best ) the days you are most available. (List the whole week)

Please also rank from 1 to 4 (1 being the best) you most preferred method of contact. (Text, Phone, Email, and Social Media)

Twitter

Facebook

Google Plus

By checking the box below and submitting this form, I am agreeing to a background check by ASPIRA and I understand that this is an official document. I am giving truthful information and understand that giving false infromation is punishable as a Misdemeanor. I also acknowledge that I have received and read the mobile mentorship program policies and guidelines. *

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ASPIRA of Florida Main Office

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