Mentor Application Form - Apply Now

BRIDGING THE GAP OF AMERICA, INC.

MENTOR APPLICATION FORM

Mentor First Name:

Mentor Last Name:

Address:

Home Number:

Work Number:

Fax:

Directions to your school or office:

In what discipline do you work? What are your other creative interests?

Do you have experience working with elementary school, junior high or high school youth? If so, please elaborate upon your experience.

If not, what aspects most concern you?

What is your interest in participating in this program?

Please give us an idea of when it is most convenient to host your student. Day/2-hr period

Mon:

Tue:

Wed:

Thr:

Fri:

I agree to host my student exclusively on weekdays during normal business hours (9am–6pm) in my school or office.
If I am unable to do so, I understand that I must contact the Project Coordinator immediately to arrange a suitable venue
for the sessions. I understand that in no instance should I host the mentorship from my home. I may take my student
on a field trip to an art gallery or museum, provided that I do so within normal business hours or obtain special
permission from the Project Coordinator.

Digital Signature (Full Name):

Date: