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BECOMING A ROLE MODEL

Fill out the web form below and click the "Submit and sign me up for orientation" button at the end to forward your application. If you have any questions? Please call 408-246-0433 or email: info@therolemodelprogram.org

* Indicates Required Field

Applicant/Teacher Information
* First Name:
* Last Name:
Middle Initial:
* Street Address:
*City:
*State:
*Zip:
* Home Phone:
Business Phone:
* Email:
Birthday:
* Gender: Female Male
* Ethnicity: African American American Indian Asian/Pacific Islander
Caucasian Hispanic Other
If other, please specify:
Are you fluent in languages other than English?: Yes No
If yes, please specify:
How did you hear about The Role Model Program?:
Education
High School:
College:
Did you attend a local middle school? Yes No
If Yes, please specify
Did you attend a local elementary school? Yes No
If Yes, please specify
Criminal History
* Felony convictions ? Yes No
Comments
Other Factors or Circumstances:
Employment Information
Current Employer:
Job Title:
Street Address:
City:
State:
Zip:
Phone:
Fax:
Time in Position:
Boss's Name:
Boss's Address (if different from above)
Boss's City:
Boss's State:
Boss's Zip:
Reference #1
First Name:
Last Name:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Association:
Reference #2
First Name:
Last Name:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Association:

Note: If desired, click on the following link to download a hard copy version of this application.

Volunteer Application Microsoft Word Document [54KB]