About Us   |   Contact Us   |   In The News   |   Translate Website

Ambassadors For Learning™ Mentorship Program Application

* Indicates required fields -

Please complete the entire form including a signature at the bottom, since an incomplete form makes the application ineligible.

*First Name:
*Last Name:
*Cleveland Clinic/Cleveland Clinic Community Hospital Employee?

Yes
No

If "Yes" please provide your Employee Number.
*Are you related to a Cleveland Clinic employee?
Yes
No		 If "Yes" please specify relationship.
  Please specify their name:
  Which Cleveland Clinic facility do they work out of?
*I am a community member:
Yes     No
*I am volunteering
(choose one):

as an individual
with my department
with my division
as a member of a mentor team

If you are volunteering with your Department or Division or as a member
of a mentor team, please list the names of the other individuals volunteering with you.
Cleveland Clinic Information
Your position and title:
Cleveland Clinic Facility:
Department:
Division:
Cleveland Clinic Phone Number:
(000-000-0000)
Cleveland Clinic Fax Number:
(000-000-0000)
Pager Number:
Mail Code:
Cleveland Clinic E-mail:
Supervisor's Name:
Supervisor's Position and Title:
Supervisor's Phone Number:
(000-000-0000)
Mail Code:
Personal Information
*County you live in:
*Personal E-mail:
*Home Phone Number:
 (000-000-0000)
Cell Phone Number:
(000-000-0000)
Home Fax Number:
 (000-000-0000)
*Gender:
Male:     Female:
*Birth Date:
 mm/dd/yy
*Marital Status:
Religion:
Ethnicity:
My hobbies include:
Bi/multi-lingual choose all that apply:
Arabic       Chinese       French
German     Greek          Hebrew
Italian        Japanese      Portuguese
Spanish      Turkish         Other
*What computer programs/applications are you proficient with?
*My Time Management Skill is:
Excellent      Good     Fair     Poor
*Best way to contact:
*Best time to contact:
Academic Information
Type of School
Name/Location of School
Major/Program Type
Diploma/Degree Earned
High School/GED:
 Yes No
Vocational/Trade/Technical:
Yes No
Professional or Diploma:
Yes No
College/University (Undergraduate):
Yes No
College/University (Graduate):
Yes No
Special Training:
Yes No
Other:
 Yes No
Mentor Information
Which Ambassadors For Learning™ Mentorship Program(s) or format(s) are you interested in participating? For more information about what's available follow this link.
Preferred Program(s)/Format(s):

Check all that apply -

An Academic Coach
A Career Coach
A Parent/Guardian/Grandparent Support Coach
A Motivational Coach
A Life Skills Coach
A Sports Team Coach
A Classroom Co-Teacher/Curriculum Facilitator
      (e.g. – via distance learning)
A Special Needs Student or Classroom Mentor
      (e.g. - autism, ADHD, mentally/physically challenged)
An E-Ambassador (e-mail mentor)
A Nutrition and Wellness/Fitness Mentor
A Time Management Mentor
A Leadership Mentor
A Financial Aid Mentor (scholarships and/or college funding)
A College Selection/Application Mentor
A Money Management Mentor (budgeting)
A specific classroom
A Classroom Co-Teacher/Curriculum Facilitator
A Special Needs Classroom Mentor
A Specific Project or Activity
A Specific School Department
A Specific School Sport
A Specific School
A Specific School District
A Specific Teacher or Team of Teachers
A Guidance Counselor Within a School or School District
Other

*What days and time of day are you available to mentor?
Days -
Mon    Tue    Wed    Thu    Fri    Sat    Sun
Hours
What are your mentoring preferences?

Preferred Countie(s) -
Ashland
Cuyahoga – City of Cleveland
Cuyahoga – East
Cuyahoga – South
Cuyahoga – West
Geauga
Lake
Lorain
Medina
Portage
Summit
Wayne
Other

Preferred School Name(s):
Preferred Grade(s):

K – 3
4 – 8
9 – 12
College (Undergraduate)
College (Graduate)
Preferred Subject(s):
 Math
Science
English
Language Arts
Social Studies
Fine Arts
Studio Arts
Music
Theatre
Technology
Librarianship
Health and Physical Education
Pre-service Teachers
Medical Students
Pre-med Candidates
Pre-law Students
Nursing Students
Allied Health Students
Other
Preferred Gender:
 Male       Female      No preference

*Describe the qualifications (educational/experience/special skills) you possess which would make you a good mentor.

*Describe any volunteer experience you have had with other mentoring programs.
*I am signing up to be a mentor because...
*Additional information that would be helpful in pairing you with a student
*How did you find out about the Ambassadors For Learning™ Program?
Please read carefully and sign below:

I understand that all applicants will be subject to a background check. We require that the applicants be "in good standing" with the Cleveland Clinic. The Office of Civic Education Initiatives looks at "good standing" as an employee or a retiree having never received ANY corrective action and this information will be verified by the employees' supervisor and/or Human Resources.

My application to be a mentor in the Cleveland Clinic Office of Civic Education Initiatives Ambassadors for Learning™ Mentorship Program is made with the understanding that I am able to meet the responsibilities required for participation.

My typed name below shall have the same force and effect as my written signature.
*Mentor's Signature: