Community Volunteer and Mentorship Program - Pathways To Success

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Community Volunteer and Mentorship Program

Home | Community Volunteer and Mentorship Program

Click here to print the application

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Name *

First

Middle

Last

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Are you a citizen of the US? *

Yes
No

Have you ever volunteered with youth students? *

Yes
No

Have you ever been convicted of a felony? *

Yes
No

Education

High School:

High School Address *

Address Line 1

Address Line 2

City

State

Zip Code

Year of last attendance: *

Did you graduate? *

Yes
No

College:

College Address:

Address Line 1

Address Line 2

City

State

Zip Code

Year of last attendance: *

Did you graduate? *

Yes
No

Degree / Field of Study:

Other Education:

Other Education Address:

Address Line 1

Address Line 2

City

State

Zip Code

Year of last attendance: *

Did you graduate? *

Yes
No

Degree:

Certification / Field:

References

(please list three references)

Name *

First

Last

Relationship: *

Company *

Phone Number *

Reference Address *

Address Line 1

Address Line 2

City

State

Zip Code

References - II

(please list three references)

Name *

First

Last

Relationship: *

Company *

Phone Number *

Reference Address *

Address Line 1

Address Line 2

City

State

Zip Code

References - III

(please list three references)

Name *

First

Last

attendance: students? last

Relationship: *

Company *

Phone Number *

Reference Address *

Address Line 1

Address Line 2

City

State

Zip Code

May we contact your references? *

Yes
No

Interests

Desired Hours Per Week *

Additional Comments (Desired Hours Per Week)

Monday times available and preferred school:

Tuesday times available and preferred school:

Wednesday times available and preferred school:

Thursday times available and preferred school:

Friday times available and preferred school:

Date Available *

Subject Interest (Math, Science, etc) *

Additional Comments (Subject Interest)

Please put a check by the school(s) you are interested in. *

Cape Henlopen School District
Milford School District
Seaford School District
Sussex Technical School District
Place me where I'm needed

Please select the grade level you are most interested in tutoring or mentoring *

K-5
6-8
9-12
Place me where I'm needed

Volunteer Experiences

Contact Name *

First

Last

Organization

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Duties

May we call your organizations contact?

Yes
No

Contact Name *

First

Last

Organization

Address

Address Line 1

Address Line 2

City

State

Zip Code

May we call your organizations contact?

Yes
No

Disclaimer and Signature

I certify that my answers are true and completed to the best of my knowledge. If this application leads to my volunteer placement, I understand that false or misleading information may lead to my release.

Name *

First

Middle

Last

Contact Us.

4 East Laurel Street
Georgetown, DE 19947
Phone: (302) 858 - 4861
Email: info@pathways-2-success.org

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