e-Mentoring Application

The Able Trust E-Mentoring Program

Thank you for your interest in volunteering for The Able Trust
Please fill out and submit the following form to apply.

* Indicates a required field.

First Name*:	Middle Name:
Last Name*:	Maiden Name:
Home Phone*:	Work Phone:
Fax:	E-mail*:
Date of Birth*:	Verify E-mail*:
Where do you access your e-mail?*:

Home Address

Address Line 1*:
Address Line 2:
City*:	County*:
State*:	Zip Code*:
How long have you lived at this address?*:

Previous address if less than 5 years

Address Line 1:
Address Line 2:
	City:	State:	Zip Code:

Employment Information

Occupation*:	Career Field*:
Employer Name*:	How long have they been your employer?*:
Address Line 1*:
Address Line 2:
City*:	State*:	Zip Code*:

Do you have a student in a Florida school?*:

YesNo

School(s):

Teacher(s):

County:

Are you a student?*: YesNo

School:

County:

Gender*:

Marital Status*:

Ethnic Origin:

Languages you speak*: EnglishSpanishCreoleOther

Volunteer Category*:	Other:
Grade level you prefer:
Highest level of education completed*:
Degree major:
Special skills or hobbies:
Computer skills:
How were you referred to this program?:

Have you ever been convicted, pled no contest, or had adjudication withheld in a criminal offense, felony, misdemeanor or are there any criminal charges now pending against you other than a minor traffic violation?*:
YesNo
If Yes, Please provide a brief explanation

Would you agree to an employee/criminal background check?*:	YesNo

I understand that I am offering my services to Florida's school systems without compensation. I certify that all information given on this application is true and complete. Any misrepresentation, omission or incorrect statement of facts called for in this application is cause for immediate dismissal of me as a volunteer. I agree, if I am a volunteer, to abide by all school board rules, regulations and policies, either published or in effect by usage and all rules, regulations and laws of the State of Florida as may be required by Florida Statues and Florida's School Board.

*By checking this box, I am stating that I have read and agreed to the above statement: