BRICKS Mentor Application Form Name: (Last)______________________ (First) ______________(M.I)__________ Address:________________________________________________________ Name of College or University Bachelors:_______________________________ Business Name/Address:___________________________________________ _______________________________________________________________ Name of College or UniversityMasters/Other:___________________________ Business Type/Product or Service: ___________________________________ Number of Hours Willing to Interact with Protégé on a monthly basis: _______ Professional
School:______________________________________________ Name and Location of High School Attended:___________________________ Name and Location of Community College Attended: Military Service? Y___ N___ If Yes: Branch ______ ____
Contact Info: Work Email Address:_____________________________________ Prefer Students with Academic Backgrounds that are:______________________ Stellar-Outstanding ? Moderate-Average ? Struggling-Courageous ? Prefer Students who live (circle all that apply): 1. North County 2. South County 3. West County 4. Central Orange County 5. East County Certification that no pending investigations exist nor prior convictions related to: Drug
Sales, Child Molestation, Child Pornography, Kidnapping, Child
Endangerment Sign ___________________________ |
