Mentors Application Form First NameLast NameStreet AddressCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweEmail AddressPhoneDesired LocationRegion/City/StateDesired Age GroupSubjectSELECTION OF CANDIDATES:Acceptance into the Mentor Program is selective. Mentors must meet all of Shared Education Solutions requirements to be accepted into the program. Shared Education Solutions is committed to providing quality mentoring and tutoring services, and we will act to ensure that all mentors and tutors are qualified and available.1. What school are you attending or did you attend, and what was/is your major(s)? (please attach transcript)2. What is your current GPA or what was your GPA upon graduation?3. Did you achieve a post-secondary degree? If yes, what is your degree?4. Do you have any other relevant licensure, such as CPR, special education, or teaching? (please attach proof)Preferred ages of children to work with:3-78-1213-1516-181. OrganizationAddressDates worked/VolunteeredHours worked/VolunteeredName & Contact for Supervisor2. OrganizationAddressDates worked/VolunteeredHours worked/VolunteeredName & Contact for Supervisor3. OrganizationAddressDates worked/VolunteeredHours worked/VolunteeredName & Contact for SupervisorWhat are your areas of interest and expertise (example: elementary math, literature, foreign languages)? What training do you have in those fields?Please list two references (other than above listed supervisors) who can attest to either your expertise or ability to work well with children. Please do not list family members:Do you have any experience working with children with special needs, disabilities, or from diverse cultural or socio-economic backgrounds? If yes, please explain.What is your native language? Are you proficient in English?What other languages are you familiar with? Please list them and rank your level of proficiency from 1-5, 1 being slightly familiar and 5 being completely fluent.In which of the above language of you comfortable to tutor or be a mentor in?Finally, please attach a 1-2 page “about me”. This piece should share a bit about your background, where you grew up, your goals in life, and anything else you find important about yourself, your experience with teaching, your discipline, school of thoughts, method of teaching etc., (This “about me” may shared with the child parents”)I understand that an incomplete form will not be accepted and will result in my being denied admission into the mentor program. I agree to submit to a background check if requested, I agree to random drug and alcohol testing and I attest that I know of no reason, personal or legal, why I should be denied admission.SUBMIT
