The ^* symbol marks required fields for submission.

^* First Name

^* Last Name

^* Address 1

   Address 2

^* City

^* State Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

^* Zip Code e.i. 20011 or 20010-4711

^* Phone Number e.i. 202-555-8989

^* Email Address

Please answer all of the following questions as completely as possible. Additional information can be expanded upon during the personal interview as necessary...

1) Why do you want to become a mentor?

2) Do you have any previous experience volunteering or working with youth? If so, please specify.

3) What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain.

Can you commit to participate in the LifeSource Foundation mentoring program for a minimum of one year from the time you are matched with a youth?

4) Yes     No

5) Mentors are required to be able to meet with a child eight hours per month and have contact at least once per week. Please explain any particular scheduling issues.