Acmp Mentor Member Application

University of Georgia / Athens Area Asian Children Mentoring Program (ACMP)

Student Application Name: _______________________________________________________________________ Year: ______ Major: _______________________ Ethnicity: ___________________________ Contact Address: ______________________________________________________________ Email Address: ________________________________________________________________ Phone Number: _________________________________ Preference for Contact: Day / Night Hobbies / Interests: ____________________________________________________________ _____________________________________________________________________________ _ Interested in being? (Mentor or member)__________________________________________ If you are applying to be a mentor, is there another person(s) you are willing and/or interested in mentoring with? Name: _____________________________________________ Preferences for a mentee (check all that apply): Male: ____

Female: ____

Any Asian Ethnicity: ____

Same Ethnicity: ____

Other (specify):________________

I am able to provide: A Social Relationship (hanging out): ____ Education About An Asian Culture: ____ Language Lessons: ____ Other: _________ Available / Possible Interaction Time (check one): Weekly: ____

Monthly: ____

Weekends: ____

Other (specify): ________________

Do you have a car on campus? Yes / No Would you be willing to travel to mentee’s home if mentee is not located in Athens?_______ Additional Comments / Requests:

***For those interested in applying to be a mentor, please keep in mind that mentoring requires a lot of time and dedication. Applications will be considered on a first come, first serve basis only for qualified individuals. Along with this application, please attach a short essay (at least 150 words) answering: 1) Why do you want to be a mentor? 2) What can you offer to the program and/or mentee? *Signature: __________________________________________ Date: ____________________ Please email completed form to: Asian Children Mentoring Program [email protected] or [email protected] *By signing this for, I agree not to harm the potential child emotionally or physically, and I am aware that ACMP is not responsible for any punitive damages.