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* 1. Name:

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* 2. Cell Phone:

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* 3. E-mail Address:

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* 4. Mailing Address:

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* 5. Emergency Contact Name and Phone Number:

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* 6. Relationship to Emergency Contact:

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* 7. Education:

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* 8. Do you speak any other languages?

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* 9. Hometown:

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* 10. Do you have any previous experience working with/interacting with persons with disabilities?

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* 11. Would you be more comfortable as a mentor for a...

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* 12. Environment Preference:

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* 13. Is there any additional information we need to be aware of when assigning you a client/employment site?

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* 14. Please list your Past/Current Employment Experience and Responsibilities. As we are an employment agency for developmentally disabled adults, your vocational experience may help us match you with one of our clients to work on employment goals.

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* 15. Do you have any prior volunteering experience? If so, what were your responsibilities?

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* 16. Are you involved in any other clubs or organizations? If so, what are they?

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* 17. What are your hobbies or interests?

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* 18. On a scale of 1 to 5, how outgoing would you say that you are?

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* 19. What would someone close to you say that your most valuable skill or talent is?

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* 20. What type of setting do you prefer?

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* 21. On a scale of 1 to 5, how well would you say that you are able to simplify directions?

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* 22. Which style best describes your habits and preferences at work?

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* 23. What do you hope to gain or get out of volunteering as a mentor for The Artisans?

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* 24. Availability: Please select hours/days you are AVAILABLE. This will help us block out a mentoring time that works with your schedule. If you have any specific preferences or requests (i.e. I am not available until 12:30 p.m. on Monday but checked 12 p.m. as that was the option available), please list them in the comment section below the availability chart.

  Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7 a.m. -8 a.m.
8 a.m. - 9 a.m.
9 a.m. - 10 a.m.
10 a.m. - 11 a.m.
11 a.m. - 12 p.m.
12 p.m - 1 p.m.
1 p.m. - 2 p.m.
2 p.m. - 3 p.m.
3 p.m. - 4 p.m.
4 p.m. - 5 p.m.
5 p.m. - 6 p.m.
6 p.m. - 7.p.m.
7 p.m. - 8 p.m.
8 p.m. - 9 p.m.

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* 25. Transportation Availability (Please check all that apply)

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