Mentor Screening This form is for those wanting to become a mentor with Women of the Dream. Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Are you currently in school?* Yes No What school are you enrolled in?*Are you currently employed?* Yes No Do you work part-time or full-time?* Part-time Full-time Do you have experience mentoring girls in urban areas? Describe below*Do you have a car?* Yes No Are you available to mentor on weekdays between the hours of 9AM and 3PM?* Yes No When are you available to mentor?*Is there other information you wish to share?Background CheckThis information will be kept confidential and secure.Will you agree to have the Women of the Dream check your background through federal and state agencies for criminal records and child abuse and neglect proceedings?* Yes No Social Security Number (Required for criminal records check)*Do you have a valid Driver’s License?* Yes No Driver License Number*State Issued*Date Issued* Date Format: MM slash DD slash YYYY Expiration Date* Date Format: MM slash DD slash YYYY Have you ever been arrested and/or convicted of a crime?* Yes No Please explain in detail. Include dates and disposition.*CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.