Mentor Application Form

July 2014
City: Zip: 
Gender: Country of Origin: Languages Spoken: 
Date of Birth: Age: 
Cell Phone: Alternative Phone: 
Family: SingleMarriedDivorcedSeperated
Name of Spouse: Children: 
How did you find out about Al Éxito? 
Would you agree to have us check your name through federal and state criminal records of child abuse and neglect proceedings? YesNo
Do you have a valid Driver's License? YesNo  If yes, exp. Date  State 
Do you have current vehicle insurance as required by Iowa law? YesNo

Work Details:
Work Phone: 
Number of Years at the Job: 
List any special interests, skills or hobbies you have:

List examples of any prior volunteer experience, especially with youth:

What motivates you to take an interest in Latino youth?

List three people who can serve as a character reference for you.
1) Name: 
City: State: Zip: 
Phone: Email:
2) Name: 
City: State: Zip: 
Phone: Email:
3) Name: 
City: State: Zip: 
Phone: Email:

If you agree to become a mentor, you agree to the following basic requirements:
As an Al Éxito Madrina / Padrino Mentor you are:
  • A guide, coach and confidant
  • Committed to connecting with Ahijadas/ Ahijados (Mentee) and Padres (Parents) for at least a minimum commitment of one year with openness to continue in the relationship on a long-term basis
  • A confident professional with great respect and understanding of the importance of Higher Education
  • Motivated to assist mentee to achieve academic success in the present and on the path to higher education
  • Excellent communicators and responsible to Al Éxito Site leaders, the mentee partnership and to parents
  • Able to provide resources and knowledge for mentees to set and reach goals.
  • Open-minded, flexible attitude, trustworthy, and a good listener
  • Driven to develop their leadership skills to strengthen community and Al Éxito.
  • Committed to maintain weekly contact with your mentee either in person or by phone
  • Committed to attending all Al Éxito monthly meetings, special events and campus visits.
Al Éxito reserves the right to accept or decline volunteers based on the information gathered. For reasons of confidentiality Al Éxito will not share this information or reasons of denial with any applicant.
I certify that the information I have supplied is correct to the best of my knowledge. I give my permission to contact the references provided and to complete a background check and a release of my motor vehicle records.