Mentor - Grands Flourish

Name*

First Last

Date of Birth*

MM

DD

YYYY

Phone*

Email*

Address*

Street Address Suite/Apartment City State ZIP Code

Race/Ethnicity*

Gender Identity*

Female
Male
Prefer not to say

Pronouns*

Preference in mentee gender? If so, please indicate here

Please note, none of the answers to the following questions will affect your candidacy to become a mentor.

Employment Status*

Employed
Not employed
Retired

Employment Information

Company Name Current Role Length Employed Work Email Address Work Phone Number

Please identify which language(s) you are conversationally fluent in

Spanish
Mandarin
French
Portuguese
Vietnamese
Italian
Arabic
Other

If other, please specify

What time frame are you able to commit to?*

How did you hear about our program?*

Social Media/Email Outreach
Poster/Flyer
Personal/Professional

What experience do you have with children? (ie. child, family member, work, volunteering, etc.)*

Have you or your family been impacted by the opioid epidemic? If so, please describe.

*Disclaimer: the opioid crisis has impacted the lives of the mentees. The question is only asked to better match mentors to mentees.

What are some of your interests and hobbies? (to assist us in making a stronger match)*

Please briefly explain why you would like to be a mentor and how our mission resonates with you.*

What do you see as your strongest skills, competencies, and attributes?*

Additional information or comments:

References

Reference 1*

First Name Last Name Relationship Phone Number Email Address

Reference 2*

First Name Last Name Relationship Phone Number Email Address

Reference 3*

First Name Last Name Relationship Phone Number Email Address

Privacy & Personal Information Policy*

I agree and understand.

"All individual information that is obtained shall solely be used to determine the level of need in the community and will only be reported in the aggregate. Additionally, any individual information provided and any level of need disclosed by the individual will only be used by a Grands Flourish associate and will not be shared with any third party without explicit written consent. All information provided by the respondent of this survey shall be stored in the strictest confidence under the requirements set forth in the The Rhode Island Identity Theft Protection Act."

Get Involved
Donate

The Grand Mentor Project

Mentor Form

Please note, none of the answers to the following questions will affect your candidacy to become a mentor.

References

The Easter Bunny Said “You Got This”

Looking for Leprechauns

Is This Really Happening To Me?

Lets Talk Lead

Together We Can

Rhode Island awarded $6.5M to fight opioid addiction

A Rhode Island Grandmother Reaches Out to Help Other Grandparents Affected by Opioid Crisis

The Grand Mentor Project

Mentor Form

Please note, none of the answers to the following questions will affect your candidacy to become a mentor.

References

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