Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Cell Phone *

(###)

###

####

Home Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent *

First Name

Last Name

Parent's Phone *

(###)

###

####

Pick-Up Information

By Car

By Public Transit

Allowed to walk home

Which days are you available to mentor? *

Tuesdays

Thursdays

Permission to Publish *

I understand that as part of my participation in AYA's program, photos, videos, electronic images, audio recordings and quotations of mine may be taken for use in publications and reports about the program. I grant permission for AYA to use such materials of the program.

Yes

No

Check the following statements after you have read them: *

I understand that I will be required to complete all the tutor/mentor orientation and all training.

I understand that the Adelante Mentor Program requires that I act professionally with my peers.

I will abide by all the rules and guidelines set by the Adelante Mentor Program.

I agree that disruptive behavior will not be tolerated

I certify to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and on subsequent application forms, is grounds for dismissal.