MAPS MENTOR APPLICATION APPLICANT INFORMATION Name: ____________________________________________________________________ Date of birth: ____________________________ Email: __________________________ Phone: ______________ Current address: ____________________________________________________________ City: ________________________________ State: ___________ ZIP Code: ____________ Languages Spoken: ____________________ Race: __________________ Income level (circle): low, middle, high EDUCATION AND EMPLOYMENT INFORMATION -PLEASE ATTACH RESMUE ALONG WITH APPLICATION- Current employer or school:______________________________________ Employer address: ______________________________________________ How long? ___________ Phone: ________________________ E-mail: _________________________________ Fax: ________________ City: __________________________ State: _________ ZIP Code: ____________ Car? (circle) Yes or No Duties: ___________________________ Major: ______________ EMERGENCY CONTACT INFORMATION Name of a relative: __________________________________________ Relationship:______________________________ Address: ____________________________________________________________________ Phone: ______________ City: ____________________________ State: __________ ZIP Code: ____________ DISABILITY INFORMATION Type: _____________________________________________________________________________________________ Accommodations: ____________________________________________________________________________________ HOW FAR ARE YOU WILLING TO TRAVEL? North Alameda County: Berkeley Oakland Albany Alameda Emeryville South Alameda County: San Leandro Fremont Hayward All Over REFERENCES Name___________________________________________________________ Phone_________________________________________ Relationship _________________________________ _____________________ SHORT ESSAY QUESTIONS Please answers questions on back of sheet 1) What qualities make you a good mentor? 2) Why is it important for you to mentor a disabled teen? AGREEMENT I authorize the verification of the information provided on this form. I have received a copy of this application. I understand that I will have to be fingerprinted. Signature: __________________________________________ Date: _____________________