Mentor Application

Required Information

First Name	Last Name
Email
Phone (Day)
Phone (Night)
Cell phone

Address
Address 2
City	State/Province	Zip/Postal Code
County
Country (US, ZA etc.)

Are you a legal resident of the United States?
Y
N

How did you learn about T1L1-LP?

What is your intended target group for using this program?

(Middle School, High School, Church Youth Group, Juvenile Court System, After school Program, Detention Facility, Summer Camp, Other)

Where is your targeted territory for using this program?:

(City, County, State, Country)

Please list the reasons why you want to use the T1L1-LP program

Please list any experience you have working with teens age 11-19, dates and locations

Optional Information

Please provide information on up to 3 Sponsors (if applicable)
Sponsor Organization 1
Address
Address 2
City	State/Province	Zip/Postal Code
County
Country (US, ZA etc.)
Phone
Contact Name


Sponsor Organization 2
Address
Address 2
City	State/Province	Zip/Postal Code
County
Country (US, ZA etc.)
Phone
Contact Name


Sponsor Organization 3
Address
Address 2
City	State/Province	Zip/Postal Code
County
Country (US, ZA etc.)
Phone
Contact Name
Other Sponsor Information

Your age:
Education Level:	Examples: H.S. Equivalency,H.S. Diploma,Associate Degree,Technical Degree,B.A.,B.S.,M.S.,J.D.,M.D.,Doctorate, Other.
Gender:	M F
Ethnicity:	Black White Latino Asian Other
Religious Affiliation:
Civic Group/Club Affiliation: