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I AM Returning Mentor Application

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20142015 I AM Returning Mentor Application






A. Personal Information

Full Name:
Last First M.I.
Permananent
Address:

Street Address Apartment/Unit #

City State Zip Code
Mailing
Address:

Street Address Apartment/Unit #

City State Zip Code




Are you currently employed?
Yes No
(If you are employed, please complete the rest of the section.
Otherwise, move on to section C.)
Home Phone: ( ) E-mail Address:

Mobile Phone:

( )

Gender:

Male

Female
Date of Birth: SSN:
Check One:

Faculty

USC Staff

Non-USC Staff

Student
Class Standing
(if it applies):

2nd year

3rd year

4th year

Graduate Student
B. Employment
Personal Information Notice
Pursuant to the Federal Privacy Act (PL 93-579) and the Information Practices Act of 1977 (civil Code Section 1798, et seq.)
notice is hereby given for the request of personal information on this form. The required personal information is voluntary.
The purpose in requesting this information is to facilitate the process determining eligibility for mentoring in the I AM
Program. Failure to provide any part of the requested information will prevent the programcoordinator fromprocessing a
background check which is required of all mentors.

I AM Returning Mentor Application
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Employer:

Title:

Years in current position:

Hours worked per week?


Business Address:
Street Address

City State Zip Code
Employment Status:

Student Worker

Permanent

Part-Time

Retired Other:


C. Availability
During which times will you be available to meet with your mentee(s)? Mark times that you will be available.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
910 am 910 am 910 am 910 am 910 am 910 am 910 am
1011 am 1011 am 1011 am 1011 am 1011 am 1011 am 1011 am
11 am12 pm 11 am12 pm 11 am12 pm 11 am12 pm 11 am12 pm 11 am12 pm 11 am12 pm
121 pm 121 pm 121 pm 121 pm 121 pm 121 pm 121 pm
12 pm 12 pm 12 pm 12 pm 12 pm 12 pm 12 pm
23 pm 23 pm 23 pm 23 pm 23 pm 23 pm 23 pm
34 pm 34 pm 34 pm 34 pm 34 pm 34 pm 34 pm
45 pm 45 pm 45 pm 45 pm 45 pm 45 pm 45 pm
56 pm 56 pm 56 pm 56 pm 56 pm 56 pm 56 pm
67 pm 67 pm 67 pm 67 pm 67 pm 67 pm 67 pm
78 pm 78 pm 78 pm 78 pm 78 pm 78 pm 78 pm

D. Preferences
Select the following conditions you would prefer to work under. (Check all that apply)

High school(s) you would like to work with:
Belmont Downtown Magnets Foshay Fremont Manual Arts
Marshall Roosevelt Roybal West Adams Prep
Number of students you would like to work with: 1 2 3 4 5 or more















































































I AM Returning Mentor Application
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G. Additional Information

Emergency Contact Person: Relationship:

Home Phone Work-Phone Cell Phone

H. MANDATORY SIGNATURE
Please read thoroughly.

The Los Angeles and the California State Boards of Education require that all school volunteers and employees be tested
for possible exposure to tuberculosis every 48 months. Volunteers must show proof of tuberculosis clearance prior to
volunteering. The initial examination must consist of a Mantoux skin test. Volunteers may be tested by their own
physician or visit a Los Angeles County Health Center.

Also, all vounteers must successfully complete a LiveSCAN background check and a one-hour online class focusing on
protecting minors.

PLEASE NOTE: You will receive directions on how to meet these three requirements once we receive your application.
Once confirmed to serve as a mentor, you will attend a mentor orientation in September; we will provide the available
time and campus location for this orientation as that date approaches.

I certify under penalty of perjury and in conformance with Education Code section 35021 that I am not required to
register as a sex offender pursuant to Penal Code section 290.

Mentor Signature: Date:

I. Office Use Only

The I AM Program coordinator will fill out this information.
School Principals Signature: Assigned School:


Please return this completed application to:
Michelle Cadena
Waite Phillips Hall (WPH), 7th Floor, Room 701
or it can be e-mailed to pullias@usc.edu

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