Apply To Be A Mentor Name(Required) First Name Last Name Phone(Required)Email Address(Required) Date of Birth(Required) MM slash DD slash YYYY Age(Required)Preferred Gender(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact InformationName(Required) Cell Phone(Required)Have you mentored at Living and Learning Enrichment Center in the past?(Required)YesNoList any experience you have had working with individuals with disabilities:(Required) Do you have any friends and/or relatives who work or volunteer with Living and Learning Enrichment Center? Please enter their names below:(Required) Any additional information you would like to share:(Required)Upload a copy of your photo ID (driver’s license or school ID)(Required)Max. file size: 8 MB.Please select all areas of interest (Unless otherwise noted, all mentors must be 16 years of age or older)(Required) Hangouts The Zone Girl Talk Comic Con Gamer's Club Anime Club Sports Club Writers' Club Cooking Club Art Classes Respecting the privacy of our clients, board members, donors, employees and volunteers of the Living and Learning Enrichment Center itself is a basic value of the Living and Learning Enrichment Center. Personal and financial information is confidential and should not be disclosed or discussed with anyone without permission or authorization from the director, Rachelle Vartanian. Care shall also be taken to ensure that unauthorized individuals do not overhear any discussion of confidential information and that documents containing confidential information are not left in the open or inadvertently shared. Employees, subcontracted employees, volunteers, and board members of the Living and Learning Enrichment Center may be exposed to information which is confidential and/or privileged and proprietary in nature. It is the policy of the Living and Learning Enrichment Center that such information must be kept confidential both during and after employment or volunteer service. Staff and volunteers, including board members, are expected to return materials containing privileged or confidential information at the time of separation from employment or expiration of service. Unauthorized disclosure of confidential or privileged information is a serious violation of this policy and will subject the person(s) who made the unauthorized disclosure to appropriate discipline, including termination. Certification I have read the Living and Learning Enrichment Center's policy on confidentiality and the Statement of Confidentiality presented above. I agree to abide by the requirements of the policy and inform my supervisor immediately if I believe any violation (unintentional or otherwise) of the policy has occurred. I understand the violation of this policy will lead to disciplinary action. Please type your full name below that you acknowledge the certification above:(Required) Living and Learning Enrichment Center has my permission to do a criminal background check on me. This will be done through the following: - Central Registry Clearance Request -Child Abuse/Neglect (Annually) - Michigan Public Sex Offenders Registry (Annually) - National Sex Offenders (Annually) - iChat (Annually) - OIG (Monthly) - SAM.GOV (Monthly)Please type your full name acknowledging and granting permission for the required background checks above:(Required) NameThis field is for validation purposes and should be left unchanged.
