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PEAK Mentor Application
PEAK Mentor Application
peakchicago
2024-08-29T14:30:03-05:00
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This field is for validation purposes and should be left unchanged.
PEAK relies on the generous support of many volunteers to carry out its mission of providing opportunities for underserved youth. We recognize the private nature of the information contained herein and as such, will treat it as confidential.
Basic Information
Name
(Required)
First
Last
Birthday
(Required)
MM slash DD slash YYYY
Current Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Cell Phone
(Required)
Work Phone
May we contact you at work?
Yes
No
I am interested in
(Required)
becoming a mentor for a day
becoming a full time, 4 year mentor
becoming a full time, 1 year mentor
Current place of employment, title, date you began this position
(Required)
Place of Employment
Title
Date began position
Preferred Email
(Required)
Secondary Email
How did you hear about PEAK?
Word of Mouth
Radio
Google Search
Other
How else did you hear about PEAK?
Educational History
Please list your educational history, starting with the most recent (school name, dates attended, name of program/degree, completed y/n).
(Required)
School Name
Dates Attended
Program/Degree
Completed? (Y/N)
Add
Remove
Interests and Activities
What has been your past volunteer experience?
(Required)
Volunteered With
When (Year)
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Remove
Why are you interested in volunteering with high school students?
(Required)
Why do you believe you would make a good PEAK mentor?
(Required)
What are your hobbies and interests? Are you involved in any clubs or groups?
(Required)
Do you have experience with any languages other than English? If yes, which language and what level?
Language
Level
Add
Remove
Describe any special skills, training, or certification that you have.
Have you received any awards or special recognition for your work, philanthropic or volunteer interests?
How would you describe yourself, or how would your close friends describe you?
(Required)
Is there anything else we should know about you or your background that would help us match you with a scholar?
Yes
No
What else would you like us to know?
Would you like to learn more about getting involved with PEAK in other ways? If so, please indicate areas of interest:
Assist with planning mentor/scholar outings
Assist with fundraising events
Assist with research and grant writing opportunities
Contacts and References
Please provide at least two professional and one personal reference (none of whom should be a relative) and include: name, phone, email, relationship, and how long they have known you
Professional References
(Required)
Name
Phone
Email
Relationship
How long have they known you?
Add
Remove
Please provide two professional references.
Personal Reference
(Required)
Name
Phone
Email
Relationship
How long have they known you?
Please provide one personal reference (should not be a relative).
Emergency Contact
(Required)
Name
Phone
Email
Relationship
Personal History
Please note: for any items that you check "yes," please explain in greater detail.
Have you ever been convicted of a criminal offense (felony or misdemeanor, other than minor traffic offenses)? Answer "yes" if you have entered a plea agreement including a deferred sentence or deferred judgment arrangement in connection with a criminal case.
(Required)
Yes
No
Explain the details of your criminal offense(s).
Have you ever been charged with a sexual offense, offense relating to children or minors, or crime of violence?
(Required)
Yes
No
Explain the details of your sexual / child related or violent offense(s).
Have you ever been the subject of a civil lawsuit involving sexual misconduct, violence, or injury involving children or adults?
(Required)
Yes
No
Explain the details of your civil lawsuit.
Have you ever been reported to any organization or registry for abuse or misconduct involving children or adults?
(Required)
Yes
No
Explain the reports for misconduct.
Do you have any disciplinary action or investigation pending by an employer, other organization, professional association, or licensing body for violence, sexual misconduct, or misconduct involving children?
(Required)
Yes
No
Explain the disciplinary actions or investigations.
Have you ever been disciplined or dismissed from any volunteer position or employment following an allegation of sexual misconduct, physical aggression, verbal aggression, or other inappropriate behavior or conduct?
(Required)
Yes
No
Explain the disciplinary actions or dismissal.
Have you ever been reprimanded or asked to leave or end your membership in a volunteer, civic, or non-profit organization?
(Required)
Yes
No
Explain the reprimand or leave request.
Have you ever been the subject of a complaint or disciplinary proceeding brought against any professional license or professional affiliation held by you?
(Required)
Yes
No
Explain the complaint or disciplinary proceeding against you.
Have you changed your name in the last 7 years?
(Required)
Yes
No
What was your previous name?
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