LIGHT: Atlanta Mentee

Application
How were you referred to LIGHT?_________________________________________________
Name:_______________________________________________________________________________________
First
Middle
Last
Gender: Male

Female

Address:_____________________________________________________________________________________
Street
City
State
ZIP
Birth Date MM/DD: __________________________ Mobile phone:____________________________________
E-mail address: ___________________________________________ Language(s): ________________________
Preferred Method of Communication: Email Phone
Education (Name, Graduation Date):

Pathway:
Work Experience:
Current Employer (Name, Employed Date):
Title:
Status: Full-time Part-time Retired
Previous Employment: (Please list any other employment experience you feel is important to note. Please
include your length of time in each position. )

What days of the week are you available to meet with your mentor? (Check all that apply):
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Select all that apply: Lunchtime After work (Weekdays) Weekends

Initial the two statements below:
_____ I understand that the mentor program involves spending a minimum of four hours per month (ie: 2 hour
sessions, with email/phone conversations bi-weekly)
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 mentor application forms, is grounds
for dismissal.

___________________________________________
Signature

___________________________________________
Date

LIGHT: Atlanta Mentors

Questionnaire
1. Why do you want to be mentored by LIGHT: Atlanta Mentors?

2. What talents and skills do you possess that you would like for your mentor to
know?

4. What do you hope to gain from your mentor?

5. Please share any additional information you would like your mentor to know
about you.

6. My favorite subject in school is ______________________________________________________

7. My least favorite subject in school is
__________________________________________________
8. Please put an X by the activities you enjoy the most:
___

Sports:
____________

___
Going to the
movies

___

Writing

___

___

Reading

___

Listening to
music such as
_________________

___
Visiting zoos
and parks

___
Hiking and
seeing
nature

___
Visiting
museums

___

___

Photography

___

Using computers

___

Attending plays

___

Playing games

Arts and crafts

___

Cooking

___
Exploring
possible
careers

Other
___________________
___________________

LIGHT: Atlanta Mentors

Application

If you choose to be a mentored, would you be willing attend LIGHT: Atlanta Mentors Meet Your Mentee
party?
Yes

No

ReferencesPlease list two references (non-relatives) who we can contact:

1. Name:
Phone/Email:
How long have you known this person?
What is your relationship to this person?
2. Name:
Phone/Email:
How long have you known this person?
What is your relationship to this person?
Criminal Record (Please circle Yes or No):
Yes

No

Within the past 10 years, have you been convicted of any felony or misdemeanor
classified as an offense against a person or family, or an offense of public
indecency or a
violation involving a state/federally controlled substance?
Yes

No

Are you under current indictment or has a district/county attorney accepted an official
complaint for any of the offenses in question #5?

If the answer is YES to questions 5 or 6, please explain below:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If you have any questions or concerns, please contact Mike Massey at lightatlantamentors@gmail.com