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Mentor Application Form
Personal Information
Ms.
Mrs.
Mr.
Dr.
First Name
M.I.
Last Name
Address
City
State
Zip
Alabama
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District of Columbia
Delaware
Florida
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Home Phone
Cell Phone
Work Phone
Fax
Email
Preferred Means of Contact
Home Phone
Cell Phone
Work Phone
Email
Employment
Company/Organization
Type of Business
Education
Manufacturing
Wholesale
Financial
Nonprofit
Other
Law
Retail
Other
Most Recent Title
Years of Service
Currently:
Employed Full-time
Employed Part-time
Retired
Education
College
Major and Degree
Graduate School
Major and Degree
Other
Experience Working with Youth
Please list any experience that would relate to your association with student mentoring
Organization
Date(s)
Position(s) Held
Organization
Date(s)
Position(s) Held
Civic
Please list organizations (civic, cultural, religious, etc.) in which you are or have been active.
Organization
Date(s)
Position(s) Held
Organization
Date(s)
Position(s) Held
Hobbies/Interests
Please indicate three personal hobbies or interests that will help us match you to students.
Music
Sports
Electronics/Technology
Reading/Writing
Traveling
Other
Outdoor Activities
Arts and Crafts
Other
Please state your interest in mentoring high school students through Common Goal.
How did you hear about Common Goal mentoring
School
Please identify your first and second preference of high school for mentoring.
First Choice
Second Choice
Ben Davis High School
1200 N Girls School Rd
Indianapolis, IN 46214
Decatur Central High School
5275 Kentucky Ave
Indianapolis, IN 46221
Lawrence Diploma Plus High School
7250 E 75th St
Indianapolis, IN 46256
New Tech @ Arsenal Tech High School
1500 E Michigan St
Indianapolis, IN 46201
Pike High School
5401 West 71st Street
Indianapolis, IN 46268
