KABA - Mentor Program Application

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MENTOR PROGRAM APPLICATION

Personal Contact information:

First Name:*	MI:
Last Name:*
Address:*

City:*
State:*
ZIP Code:*
Home Phone:*

Business Contact Information:

Business Name:*
Business Address:*

E-Mail:*
Referred By:*

City:*
State/Zip:*
ZIP Code:*
Business Phone:*
Business Fax:

Preferences/Availability

Would you prefer to mentor a:* Girl Boy No Preference

You will be spending 30-45 minutes each week with your student at the site.
Check dates and times you would be available:*

Monday	Morning	Afternoon
Tuesday	Morning	Afternoon
Wednesday	Morning	Afternoon
Thursday	Morning	Afternoon
Friday	Morning	Afternoon

Please select the school(s) you would be able to mentor at:*

Bose
Brass Community
Columbus
Curtis Strange
	Edward Bain School of Language & Art
Forest Park
Frank
Grant

Grewenow
Harvey
Jefferson
Jeffery
	Kenosha County School (Salem, Trevor, Randall)
	Kenosha School of Enhanced Technology Curriculum
McKinley
Pleasant Prairie

Prarie Lane
Roosevelt
Sommers
Southport
Stocker
Vernon
Whittier
Wilson

Please read the following statements and sign your name:
In applying to become a KABA student mentor, I understand and agree to the following:

My application will be reviewed and screened. I authorize Kenosha Area Business Alliance or its
agent to perform a personal background check. I understand that the information I provide
below will be used for the personal background check. All information will be kept strictly
confidential by the third-party representative. KABA will not see any reference or background
check information. The reference check takes approximately two weeks.

I will participate in a personal interview with a qualified third-party representative as part of the
screening process.
Once accepted as a mentor for a student, I agree that all contact with the student will be inside
the student’s school and only after the student has been released from class by either his/her
teacher or other school official.
Once placed I will make every effort to meet weekly with the student and to keep the school
informed should my schedule change or I am unable to attend.

Signature:*
Maiden Name:
Previous Married Name(s):

Sex:	Male Female
Ethnicity:
Date of Birth:	/ / (mm/dd/yy)

References

Please provide the names and phone numbers of four personal references that you have known for at
least one year. A minimum of three references will be contacted by phone using a third-party
representative. Please notify references that they will be contacted. NOTE: Do not list relatives.

Reference Name (first, last):	Reference Phone Number:
1.) *	1.) *
2.) *	2.) *
3.) *	3.) *
4.)	4.)

Or, if you would perfer you may print the application and submit via Mail or Fax:

Mail: KABA Mentor Program
Kenosha Area Business Alliance
600 52nd Street, Suite 120
Kenosha, WI 53140

Fax: (262) 605-1111