The Yasmine MBI Mentorship Program

APPLICATION

We will need some personal information about you and your spouse (if applicable) and four references. Please contact admin@bold180Youths.org with any questions regarding our Mentoring Program or the application process.

To be a mentor, you must:

Be 21 years of age or older
Pass a mandatory screening
Have a valid Driver’s License and auto insurance
Commit to spending 4-to-6 hours per month one-on-one with a mentee

Mentoring Application

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What is your age? Must be 21 or older to mentor

How did you hear about our Mentoring program?

Group affiliation (if applicable)

Name

First

Last

Phone

Your Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Your Employer

Your Gender

Male
Female
Non-binary /other

Date of Birth

Spouse's Name

First

Last

Spouse's Phone Number

If yes, please give start/end dates and location(s).

First Reference Name

First

Last

First Reference Email

First Reference Phone Number

Relationship to First Reference:

Second Reference

Second Reference Name

First

Last

Second Reference Email

Second Reference Phone Number

Relationship to Second Reference:

Third Reference

Third Reference Name

First

Last

Third Reference Email

Third Reference Phone Number

Relationship to Third Reference

Fourth Reference

Fourth Reference Name

First

Last

Fourth Reference Email

Fourth Reference Phone Number

Relationship to Fourth Reference: