MENTOR/VOLUNTEER REGISTRATION
* required field
*
Salutation:
Please select applicable one
Mr.
Ms.
Mrs.
Dr.
*
First Name:
Middle Name:
*
Last Name:
Organization/ Affiliate (if any):
*
Mailing Address
*
City:
*
State:
*
Zip Code:
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*
Phone:
(ex: 334-999-9999)
Fax:
(ex: 334-999-9999)
Email:
County or Counties of Interest:
For Background Check Purposes Only:
*
Date of Birth:
(ex: 12/13/1978)
*
Gender:
Race:
Please select applicable one
Male
Female
Please applicable one
Asian
Black
Hispanic
American Indian
Other
White
I would like for mentoring organizations in my area to contact me directly regarding their programs
I prefer to utilize the list of available mentoring organizations in my area provided by MENTOR
I understand MENTOR ALABAMA will
conduct criminal background checks
on prospective mentors. I consent to a criminal background check for these purposes. I also understand that background checks are conducted to fight crime through appropriate mentor/mentee contact.