Positive Alternatives, Inc.
A United Way Sponsored Agency
Phone (715) 235-9552
Date:______________
Name:_____________________________________Age:_______Birthdate:_______________Sex:_____
School Address:__________________________________________Phone#:_________________
Home Address:___________________________________________Phone#:_________________
Social Security# _____-____-_____Driver’s License#_________________Work#_______
E-mail Address_______________________
Work and Volunteer Experience
TYPE OF WORK EMPLOYER/VOLUNTEER SUPERVISOR
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
List any previous experience working with children (volunteer or paid) ________________________________________________________________________________________________________
_____________________________________________________________________________________________________
What are your hobbies and interests?__________________________________________________________________
______________________________________________________________________________________________________
What do you feel you can contribute to a child?_______________________________________________________
______________________________________________________________________________________________________
What do you hope to receive from the program?_________________________________________________________
______________________________________________________________________________________________________
Preferred school in which to receive a mentee: Oaklawn Downsville River Heights Knapp
Wakanda Cedar Falls High School Middle School
Preferred Age Group:_________________________
Would you be willing to drive to Knapp or Downsville? Y/N
Personal References
Please use complete mailing address
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NAME/ADDRESS |
COMPANY NAME/TITLE POSITION |
AREA CODE AND PHONE NUMBER |
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AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
I understand it will be necessary for The Mentor Program to investigate my background and to check my personal references. I, Hereby give my consent for this information exchange and authorize such agencies or persons to release any information requested by The Mentor Program. I understand that the agencies to be contacted may be employers, courts, police, social services, and any other person of agencies I have had contact with.
SIGNED___________________________ DATE__________________
For more information concerning the
Menomonie School Mentor Program contact:
Megan Weibel or Jamie Lawrence-Olson
Positive Alternatives, Inc.
715-235-9552
streetoutreach@positive-alternatives.org
jlawrence-olson@positive-alternatives.org
Please return completed application to Positive Alternatives, Inc.