Form Center

4. General Information
6. Full Legal Name*
7. Date*
   Date
9. Home Address*
11. City*
12. State*
13. Zip*
15. Mailing Address - if different than above
17. City
18. State
19. Zip
21. Phone Number*
22. Phone Type*

    1. Home
    2. Work
    3. Cell
23. If this is a cell phone, are texts okay?

    1. Yes
    2. No
25. Best Time to Contact You*
26. Email Address*
28. How did you hear about us?*

    1. Event Booth
    2. Flyer
    3. Presentation
    4. Social Media

    1. Word of Mouth
    2. Workplace
    3. Other
30. If you chose "Other", please tell us more.
34. Education and Employment
36. Highest Level of Education Earned*
    -- Select One --High SchoolSome CollegeTrade/VocationalBachelorsMastersDoctorate
37. Current Employer*
38. Current Position*
40. Employer Address*
42. City
43. State
44. Zip
46. Special Skills or Training*
47. Foreign Language?*
51. References

    Please list three references including email and phone number so that we may contact them (no relatives).

53. Reference 1 Name*
54. Relationship to You*
56. Email*
57. Phone*
61. Reference 2 Name*
62. Relationship to You*
64. Email*
65. Phone*
69. Reference 3 Name*
70. Relationship to You*
72. Email*
73. Phone*
77. Emergency Contact*
78. Phone*
82. Statement of Agreement

    Please fill out the form below. A criminal background check is also required as a precautionary measure in protection of the Aspire Mentoring Program, the children/families we serve, and the city of Longview. That form will be completed at New Mentor Orientation. Read each statement, select, "Yes", and indicate agreement by your signature below.

84. Statement 1*
    -- Select One --YesNo

    I agree not to consume, use, possess, or be under the influence of any drug or alcohol products while volunteering for the City of Longview.
85. Statement 2*
    -- Select One --YesNo

    I understand that any conduct or pattern of conduct that would tend to disrupt, diminish, or otherwise jeopardize public trust in the City of Longview will result in dismissal.
86. Statement 3*
    -- Select One --YesNo

    I understand that my volunteer assignment with the City of Longview may be terminated at any time.
88. Statement 4*
    -- Select One --YesNo

    I understand that depending upon the nature of the volunteer assignment, the City of Longview may deem it necessary to obtain a Driver's License Record and/or a Criminal Conviction History and Wanted Information Reports on individuals volunteering for the City of Longview. I hereby consent to the City of Longview to make any requests for a Drivers License Record, a Criminal History Report, and/or a Wanted Information Report on me. I release, relinquish, and remise the City of Longview, its employees,agents, and representatives, from any and all causes of action or liability which I may have or which arise out of, or as a result of, the reports herein authorized. Furthermore, I understand that my failure to execute this informed consent will result in my not being further considered for employment or volunteerism.
89. Statement 5*
    -- Select One --YesNo

    I have NOT been convicted and/or placed on probation for any criminal offense.
91. Statement 5 - Addendum 1
    If you HAVE been convicted and/or placed on probation, please list date and nature of offense.
93. Previous Addresses*
    List any states you have lived in besides Texas and how long you resided there.
95. E-Signature*
96. Date
    Date
100. Mentor Survey

     This information will help us know more about you and allow us to match you with a Mentee that is compatible with you. Please fill this out as correct and honestly as you can.

102. Name
104. Ethnicity
105. Gender

     1. Male
     2. Female
     3. Non-binary
     4. Prefer not to answer
107. Marital Status
108. Spouse/Partner Name
110. Do you have children living at home? If so, what are their grades and schools?
112. Days that you could meet with your Mentee*

     1. Monday
     2. Tuesday
     3. Wednesday

     1. Thursday
     2. Friday
     3. Weekends
113. Times that you could meet with your Mentee*

     1. Lunchtime
     2. Evening
     3. Other times during the School Day
115. Preferred School District*
116. Preferred Campus*
118. Which age group are you interested in working with?*

     Select all that apply

     1. Elementary: Grades 1-5
     2. Middle/JH: Grades 6-8
     3. High School: Grades 9-12
120. Would you have any concerns about with any of the following children?

     Select all that apply

     1. Very active child
     2. Child of a different race
     3. Child with learning disability

     1. Child with behavior problems
     2. Child with ADHD

     1. Overweight child
     2. Child with emotional problems
122. How would you describe yourself?*

     Select all that apply

     1. Outgoing
     2. Friendly
     3. Musical/Theatrical
     4. High Energy

     1. Athletic/Enjoys Sports
     2. Outdoorsy/Enjoys Nature
     3. Prefers Indoor Activities
     4. Computer/Tech Enthusiast

     1. Shy
     2. Quiet
     3. Laid Back
     4. Other
124. Hobbies/Interests*
126. Why would you like to become a mentor?*
Leave This Blank:


128. 1. Receive an email copy of this form.
129. Email address

     This field is not part of the form submission.

130. Submit

* indicates a required field