Office Use:

Date Received:
Last Updated: July 1, 2011

Mentoring Program MENTOR Application

Date:

A) Personal Information
1. First Name:

2. Middle Name:

3. Last Name:

4. Address:

Apt.

5. City:

6. State:

8. Home Phone: (

7. Zip Code:

9. Cell Phone: (

10. Email(s):
11. Birth date:

12. Age:

13. Sex: 1-Male ____ 2-Female ____

14. Birthplace:
15. If you were born outside the United States, at what age did you arrive here?
16. Other countries you have lived before you came to the United States:

17. Ethnicity:

1-Bangladeshi___
7-Korean___

2-Cambodian___ 3-Chinese___ 4-Filipino___

8-Pakistani____ 9-Thai___

10-Vietnamese___

5-Indian___

6Japanese___

11-Other (please specify)

18. What language(s) do you speak?

1-English___

2-Mandarin___

3-Cantonese___

7-Korean___

8-Japanese___

9-Tagalog ___

4-Toishanese___

5-Fukienese ___

10-Vietnamese ___

6-Taiwanese___

11-Cambodian___

12-Thai

___
13-Bengali___

14-Urdu___

15-Punjabi___

16-Other (please specify)

19. What language(s) do you read and write?

Select a number(s) from above (Write 17 for Chinese) ___________________________________________
20. What is your religion?
1-Confucianism____

2-Buddhism____

3-Christianity____

6-Taoism____ 7-Islam____ 8-Agnosticism____

4-Catholicism____

5-Hinduism____

9-Atheism____ 10-Other (please indicate) ______________

21. Do you have any dietary restrictions or allergies? Please indicate:

22. What is your marital status?

1.____single 2.____engaged 3.____married 4.____domestic partner

5.____divorced

6.____widowed

7._____other

23. Do you have any children? 1-Yes_____ 2-No____ If yes please indicate gender(s), age(s) ___________________
24. What is your annual income?
1-$0-$9,000 __ 2-$10,000-$19,000 __ 3-$20,000-$29,000 __ 4-$30,000-$39,000 __ 5-$40,000-$49,000 __
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6-$50,000-$59,000 __ 7-$60,000-$69,000 __ 8-$70,000-$79,000 __ 9-$80,000- $89,000 __ 10-$90,000-$99,000__

11-$100,000+ __

2. Employment Information
5

25. Current Employer:

26. Title / Position:

27. Number of years with current employer:

28. Start Date:

29. Address: _______________________________________________________________________________________

30. City:
33. Phone: (

31. State:
)

32. Zip Code:

34. Fax: (

35. Presently, does your job require to work weekends or to travel? 1-Yes___ 2-NO___ 36. If yes, how often? ________

3. Other Work Experience

5

37.

Position:

Employer:

Address:

Phone:

1.________________________________________________________________________________________________
2.________________________________________________________________________________________________
3.________________________________________________________________________________________________
4.________________________________________________________________________________________________
5.________________________________________________________________________________________________
6.________________________________________________________________________________________________

D) Educational Background
38. Highest level of education completed:
1-High School____ 2-Some College_____ 3-Associate Degree_____ 4-Bachelors Degree_____
5-Masters Degree_____ 6-Professional Degree (e.g., Ph.D., Dr., Law):____________________
39. Graduate / Professional School:

40.Graduation Date:

41. Field of study:

42. Degree:

43. Undergraduate School:

44. Graduation Date:

45. Major:

46. Degree:

47. High School (name/state):

48. Graduation Date:

49. Are you currently enrolled in school? 1-Yes__ 2-No__

50. If so, are you attending school? 1-Part time__ 2-Full time___
51. Name of College/ University: ___________________________________________________ 52. GPA:
____________
53. Major/ Field of study: _____________________________________________ 54. Minor________________________
55. Year in College/ University:
College:

1-Freshmen____

2-Sophomore____

56. Anticipated graduation date: ____________________________

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3-Junior____

4-Senior____

E) Activities / Interests / Skills

57. Professional Affiliations:
_________________________________________________________________________________________________
58. Current/prior organizations and positions held:

59. Hobbies / interests:

_________________________________________________________________________________________________
60. Have you worked with other youth programs?

1-Yes___

2-No___

61. If yes, please describe:

62. Would you be interested in sharing your knowledge and skills to assist with other APEX activities (e.g., providing
information for youth workshops, planning social events, volunteering to assist with the Annual Benefit and other
fundraising events, etc.)?
1-Yes ___ 2-No ___

53. If yes, please specify

F) Match Preferences
63. I prefer to be matched with a student of the same ethnicity: 1-Yes___

2-No___

3-It doesnt matter___

64. I prefer to be matched with a: 1-Recent immigrant __ 2-Assimilated/American-born student__ 3-No preference__
65. I prefer to be matched with a: 1-9 th-10th grader ___ 2-11th-12th grader___ 3-6th-7th grader__ 4-No preference ___
66. I prefer to be matched with a student who needs help in the following areas (check all that apply):
1-Building self-confidence and sense of self worth ____
2-Assisting with school work and/or improving English skills ____
3-Gaining greater knowledge and awareness of Asian culture as well as others____
4-Doing recreational//social activities (e.g. sports, games, etc.) ____
5-Improving communication skills to establish healthy and satisfying relationships ____
6-No preference ____
67. How did you hear/find out about APEX?
1. Internet
2.Friend
please specify

please specify

3.Event

4. Other

please specify

please specify

68. Would you be willing to be placed on a waiting list if not matched?

1-Yes_____

2-No_____

G) Time Commitment
5

High School Mentors:

1. One year time commitment
2. Meet with mentee every other week for minimum 2 hours (off-site)
3. Attend mentor training session
4. Bi-weekly phone/email check-in with program coordinator
5. Attend feedback sessions (one per semester)
6. Attend 3 out of 6 group events during the year
7. Attend 1 out of 3 educational workshops during the year
8. Participate in end-of-the year evaluation session (will be required to fill out surveys and forms)
69. Can you commit to these requirements?

1-Yes____ 2-No____
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Middle School Mentors:

1.
2.
3.
4.
5.
6.
7.
8.

One year time commitment

Meet with mentee every other week for minimum 2 hours (on-site at designated school every other Saturday)
Attend mentor training session
Bi-weekly phone/email check-in with program coordinator
Attend feedback sessions (one per semester)
Attend 3 out of 6 group events during the year
Attend 2 out of 3 educational workshops during the year
Participate end-of-the year evaluation session (will be required to fill out surveys and forms)

70. Can you commit to these requirements?

1-Yes____ 2-No____

H) Personal Statement
*In a brief essay (1 page or less), describe why you want to join APEX as a mentor and what you have
to offer as a mentor to an Asian American student. (Please attach to the application.)*

I) References
Please provide three references of people who have known you for at least one year. One of these references must be
your current work supervisor. Please do not list relatives as references. References will be contacted by phone or e-mail,
and information they provide will remain confidential.
71-Name:

Telephone #:

Relationship:

E-mail:
Address:
City:

State:

72-Name:

Zip:

Telephone #:

Relationship:

E-mail:
Address:
City:

State:

73-Name:

Zip:

Telephone #:

Relationship:

E-mail:
Address:
City:

State:

Zip:

J) Availability for Interview Dates

74. Available days and times (interviews are approximately one hour):
( ) Monday

( ) Tuesday

( ) Wednesday

( ) Thursday

( ) Friday

( ) Morning/ Time: _________ ( ) Afternoon/ Time: _________ ( ) Evening/Time: ________

We will contact you to confirm your interview time.

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K) Verification of Application Information and Consent for Photo Usage

I have read and agree to the following:
By signing, to the extent permitted by law, I release and discharge APEX and its officers, agents, representatives and
employees from any action, claim or liability which may arise in the future in connection with my participation as a
volunteer in APEXs programs. I also agree that APEX shall note in any way responsible or liable for my conduct or the
conduct of any parent, guardian, or child participant and other volunteers.
I grant permission for APEX to record any or all of my participation in its programs for photos, TV, radio, motion pictures,
videotapes, and websites for use in publicity, promotions, fundraising or advertising without compensation.
I further agree to indemnify, to the extent permitted by law, APEX and its officers, agents, representatives, and
employees against any action or claim asserted by any person or entity and arising out of my gross negligence or willful
misconduct in connection with my participation as a volunteer in APEXs programs.
I have read the above statement and understand that photos of me, sometimes with my name, may be used in APEX
publications and materials. I give my consent to APEX for such photo and name usage. Furthermore, all the information
I have provided in this application is true to the best of my knowledge.
Name (please print)
Signature

Date

PLEASE NOTE: Volunteers working with youth are required to undergo a background check. Due to a
legislative change in March 2011, the background check fee is now $60. APEX is subsidizing half of the cost
as a courtesy to you, and asks that you bring $30 (cash or check) to the interview if contacted. Thank you.
PLEASE SEND YOUR COMPLETED APPLICATION TO:
APEX
Mentoring Programs
80 Maiden Lane, 11th Floor, New York, NY 10038
Fax: 212-748-1250
Email: [email protected]
For further questions or information, please contact:
Kristine Chin, Program Coordinator
Phone: 212-748-1225 (ext.103)
Email: [email protected]

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