ASPIRA of Florida Corporate Offices

email-icon-vector6100 Blue Lagoon Drive, Suite 460

Miami, FL 33126

                   Voice: (305) 269-6767

                   Fax: (305) 269-6722

 

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ASPIRA of Florida

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ASPIRA / SPRINT Mobile Mentorship Program Form

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MENTORSHIP COMMITMENT

    • Mentors will commit to at least one interaction with mentee per semester for the 2016-2017 school year outlining short term and long term goals.
    • Mentors will commit to being available for school,career,and mentorship coaching via text at least once a month for the duration of school year.
    • Mentors will commit to meeting with mentee and doing a mid-semester and end-of-semester evaluation form detailing accomplishments and new goals.
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* Required information.
Application Date *
* I acknowledge that I understand my Social Security Number will be collected for the use of state mandated background checks only . *
Name *
Home Address *
City, State and Zip Code *
Home Phone
Work Phone *
Cell Phone *
E-mail Address *
Gender
Male
Female
Ethnicity
Date of Birth *
Emergency Contact's Name *
Emergency Contact # *
Current Employer /Organization/Affiliation *
Dates Employed *
Past employers/Organizations/Affiliations
Dates Employed
Are you bilingual? *
Primary Language
English
Spanish
Other
Are you a parent/guardian/family member of (a) student(s) ? *
If you are an ASPIRA/SPRINT employee please provide your employee number
Are you an active or former member of law enforcement, a firefighter, a Department of Children & Family Services employee, a judge, a state or assistant attorney, a prosecutor, a government employee with duties involving human resources, labor relations, code enforcement officers or a spouse or child of the foregoing categories? *
Have you ever entered a plea of Nolo Contendere (no contest), a plea of Guilty, been placed in pre - trial intervention program or on probation, or been fined in a criminal proceeding? *
Have you ever received an adjudication of guilt, had adjudication withheld, had a criminal case result in a nolle prosequi ("nol pros"), or had a criminal record sealed or expunged? *
Please rank from 1 to 7 ( 1 being the best ) the days you are most available. (List the whole week)
Please also rank from 1 to 4 (1 being the best) you most preferred method of contact. (Text, Phone, Email, and Social Media)
Twitter
Facebook
LinkedIn
Google Plus
By checking the box below and submitting this form, I am agreeing to a background check by ASPIRA and I understand that this is an official document. I am giving truthful information and understand that giving false infromation is punishable as a Misdemeanor. I also acknowledge that I have received and read the mobile mentorship program policies and guidelines. *