B. General Information

First Name: Last Name:

Email: (required) Re-enter Email:

Work Phone : Home Phone:

Cell Phone:

Street Address:

City:

State: California Nevada Arizona Alabama Alaska Arkansas Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:

I prefer to be contacted: At home At work By cellphone By email

C. Personal Information

Date of Birth: Gender: Male Female Transgender

Marital Status: Single Married Separated Widowed

Ethnicity (Please select all that apply): African American/ Black Latino/Hispanic White/Caucasian Asian Native American/Alaskan Native Pacific Islander Other If other, please specify:

Do you speak any language other than English? If so, please list:

Please list all the members of your household in which you currently live:

Name: Gender Date of Birth Relationship to Self

Name: Gender Date of Birth Relationship to Self

Name: Gender Date of Birth Relationship to Self

Name: Gender Date of Birth Relationship to Self

What's your highest level of education completed: Less than high school diploma High school equivelancy/GED High school diploma Some college Vocational/technical business school Associate Degree (2 years) Bachelor's degree (4 years) Master's degree Doctorate (PhD, JD, MD)

What is your current employment status: Full-time Part-time Not in labor force Seeking employment Homemaker Student Retired

What is your current occupation:

If you are currently employed, who is your employer:

E. Background (Note: An answer of "yes" to any of these questions will not automatically disqualify you from the program.)

Have you ever had an alcohol or substance abuse problem? If yes, please explain.

Have you ever been arrested or convicted of a crime? If so, please explain and list dates.

F. Match Preferences

Why do you want to become a mentor?

List any hobbies or interests you would like to share with a mentee.

Please list 5 words that describe your personality.

What kind of experience do you have working with or being around children?

In order to help us best match you with a mentee, please select your preference(s), if any. Please select all that apply.

Age: 4-6 7-10 11-14 15-18 No preference

Ethnicity: African American/ Black Latino/Hispanic White/Caucasian Asian Native American/Alaskan Native Pacific Islander Other No Preference If other, please specify:

Would you be willing to work with a child with special needs: Yes No

If yes, please specify:

Do you have your own transportation (other than a motorcycle)? Yes No

Is your vehicle insured and in good working condition? Yes No

How did you first hear about OreMi (Please select all that apply)? Friend/Relative Church, synagogue, etc. Advertisement School Website Other

Please specify:

I understand that FSSBA is not obligated to provide a reason for their decision of accepting or rejecting me as a mentor in the
OreMi Mentoring Program. By checking this box, I attest to the truthfulness of all information listed on this application and
agree to all the above terms and conditions.