Sign up to become an I AM Mentor! For more information or an application Contact the Pullias Center By e-mail at pullias@usc.edu OR by phone at 213-740-7218 Mentors are USC students, faculty, and staff. Time commitment is 34 hours a month. I AM New Mentor Application Page 1 of 4
20142015 I AM New Mentor Application
A. Personal Information
Full Name: Last First M.I. Permananent Address:
Street Address Apartment/Unit #
City State Zip Code Mailing Address:
Street Address Apartment/Unit #
City State Zip Code
Home Phone: ( ) E-mail Address:
Mobile Phone:
( )
Gender:
Male
Female Date of Birth: SSN: Check One:
Faculty
USC Staff
Non-USC Staff
Student Class Standing (if it applies):
2nd year
3rd year
4th year
Graduate Student How did you hear about our program? Flyer Presentation Other ____________ Email Friend Personal Information Notice Pursuant to the Federal Privacy Act (PL 93-579) and the Information Practices Act of 1977 (civil Code Section 1798, et seq.) notice is hereby given for the request of personal information on this form. The required personal information is voluntary. The purpose in requesting this information is to facilitate the process determining eligibility for mentoring in the I AM Program. Failure to provide any part of the requested information will prevent the programcoordinator fromprocessing a background check which is required of all mentors.
I AM New Mentor Application Page 2 of 4
Undergraduate Institution Undergraduate Major Undergraduate Minor Hobbies
Are you currently employed? Yes No (If you are employed, please complete the rest of the section. Otherwise, move on to section C.) Employer:
Title:
Years in current position:
Hours worked per week?
Business Address: Street Address
City State Zip Code Employment Status:
Student Worker
Permanent
Part-Time
Retired Other:
D. Availability During which times will you be available to meet with your mentee(s)? Mark times that you will be available.
E. Preferences Select the following conditions you would prefer to work under. (Check all that apply)
High school(s) you would like to work with: Belmont Downtown Magnets Foshay Fremont Manual Arts Marshall Roosevelt Roybal West Adams Prep Number of students you would like to work with: 1 2 3 4 5 or more
F. Please answer the following questions.
Why do you want to be a mentor?
Do you have any previous experience volunteering or working with youth? If so, please explain.
The I AM Program requires that you meet with your mentee(s) for two to three hours per month, on a schedule determined by you and the mentee(s). How do you plan to meet this requirement? Indicate the time and location you would meet your mentee(s).
What do YOU want to gain from this experience?
G. Additional Information
Emergency Contact Person: Relationship:
Home Phone Work-Phone Cell Phone I AM New Mentor Application Page 4 of 4
H. MANDATORY SIGNATURE Please read thoroughly.
The Los Angeles and the California State Boards of Education require that all school volunteers and employees be tested for possible exposure to tuberculosis every 48 months. Volunteers must show proof of tuberculosis clearance prior to volunteering. The initial examination must consist of a Mantoux skin test. Volunteers may be tested by their own physician or visit a Los Angeles County Health Center.
Also, all vounteers must successfully complete a LiveSCAN background check and a one-hour online class focusing on protecting minors.
PLEASE NOTE: You will receive directions on how to meet these three requirements once we receive your application. Once confirmed to serve as a mentor, you will attend a mentor orientation in September; we will provide the available time and campus location for this orientation as that date approaches.
I certify under penalty of perjury and in conformance with Education Code section 35021 that I am not required to register as a sex offender pursuant to Penal Code section 290.
Mentor Signature: Date:
I. Office Use Only
The I AM Program coordinator will fill out this information. School Principals Signature: Assigned School:
Please return this completed application to: Michelle Cadena Waite Phillips Hall (WPH), 7th Floor, Room 701 or it can be e-mailed to pullias@usc.edu