WE ARE INVITING FUTURE LEADERS TO ATTEND OUR ANNUAL YOUTH by tGpvUCu7

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									                MENTOR/FACILITATOR APPLICATION

Fax your application to 979-458-4168 or mail it postmarked no later than April 15, 2010
to:
Texas Youth Leadership Forum c/o Eric Roberts
      Department of Educational Psychology
      4225 Texas A&M University
      College Station, Texas 77842-4225
If you have questions, contact Eric Roberts at 979-458-4168 or eric.roberts@tamu.edu.


PERSONAL INFORMATION
___________________________________________________________________________
Last Name                             First

___________________________________________________________________________
Address                    City                  State           Zip

__________________________________                  _____________________________________
Home Phone Number (include area code)               Fax Number (include area code)

__________________________________                  _____________________________________
Work Phone Number (include area code)               Email Address

__________________________________                  _____________________________________
Birth Date (MM/DD/YY)                               Social Security Number

T-Shirt Size: S          M             L                XL            2XL   3XL

Explain your interest in being a YLF mentor.

________________________________________________________________

___________________________________________________________________________


                               Mentor/Facilitator Application | Page 1 of 3
QUALIFICATIONS

Educational _______________________________________________________

___________________________________________________________________________

___________________________________________________________________________


Professional ______________________________________________________

___________________________________________________________________________

___________________________________________________________________________


Technical _________________________________________________________

___________________________________________________________________________


Other ___________________________________________________________

___________________________________________________________________________


REFERENCES
Please provide two references.

(1)   _____________________________________________________________________
      Last Name                             First

      _____________________________________________________________________
      Address                    City                  State           Zip

      ______________________________________________________________________
      Phone Number (include area code)      Email Address


(2)   _____________________________________________________________________
      Last Name                             First

      _____________________________________________________________________
      Address                    City                  State           Zip

      ______________________________________________________________________
      Phone Number (include area code)      Email Address

                                 Mentor/Facilitator Application | Page 2 of 3
ADDITIONAL INFORMATION
If applicable, please specify your disability. _________________________________________

___________________________________________________________________________

Would you require any accommodations in the following areas?

      Housing                      No        Yes
      Transportation               No        Yes
      Meals                        No        Yes
      Communication                No        Yes
      Other                        No        Yes (please describe): ____________________

                                   ________________________________________________

                                   ________________________________________________



    I understand and give my consent to a KBI background check.
    I understand that the people I listed as references will be contacted.
    I understand the requirements of the position for which I am applying.
    I understand the commitment to participate for the entire session and that I will be
     required to stay on campus in the dorm for the entire YLF and attend all staff meetings.
    I understand that my lodging, transportation and meals will be provided.
    I understand that––along with the rest of the volunteers––I am responsible for the
     supervision of student delegates and am legally responsible for my actions while at YLF.
    I understand that I am responsible for my actions and do not hold Texas YLF liable for
     those actions or the ramifications of those actions.
    I give my permission for the Texas Youth Leadership Forum to print or publish
     photographs and video of me, and to use quotations from me for YLF publicity efforts.



____________________________________________                            __________________________
Signature                                                               Date




                                Mentor/Facilitator Application | Page 3 of 3

								
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