Skip to Main Content
Loading
Close
Loading
Search
Government
Departments
Services
Community
Connect
Home
Form Center
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
City Government
Community Services
Contact Us
Development Services
Environmental Health
Fire Department
Library
Longview Convention Complex
Main Street
Municipal Court
Parks and Recreation
Partners in Prevention
Police - Contact Us
Police Department
Sanitation and Recycling
Water Utilities
By
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
Aspire Mentoring Program Application and Survey
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Step One
This section is complete
This section is incomplete
2.
Statement of Agreement
This section is complete
This section is incomplete
3.
Mentor Survey
This section is complete
This section is incomplete
Step One
Full Legal Name
*
Date
*
Date
Home Address
*
City
*
State
*
Zip
*
Mailing Address
If different than above
City
State
Zip
Email Address
*
Phone Type
*
-- Select One --
Home
Work
Cell
Phone Number
*
Best Time to Contact You
*
Are texts okay?
Yes
No
How did you hear about us?
*
Event Booth
Flyer
Presentation
Social Media
Word of Mouth
Workplace
Other
If you chose "Other", please tell us more.
Education and Employment
Highest Level of Education Earned
*
-- Select One --
High School
Some College
Trade/Vocational
Bachelors
Masters
Doctorate
Current Employer
*
Current Position
*
Employer Address
*
City
State
Zip
Special Skills or Training
*
Foreign Language?
*
References
Please list three references including email and phone number so that we may contact them (no relatives).
Reference 1 Name
*
Relationship to You
*
Email
*
Phone
*
Reference 2 Name
*
Relationship to You
*
Email
*
Phone
*
Reference 3 Name
*
Relationship to You
*
Email
*
Phone
*
Emergency Contact
*
Phone
*
Continue
Statement of Agreement
Instructions
Please fill out the form below. A criminal background check is also required as a precautionary measure in protection of the Aspire Mentoring Program, the children/families we serve, and the city of Longview. That form will be completed at New Mentor Orientation. Read each statement, select, "Yes", and indicate agreement by your signature below.
Statement 1
*
-- Select One --
Yes
No
I agree not to consume, use, possess, or be under the influence of any drug or alcohol products while volunteering for the City of Longview.
Statement 2
*
-- Select One --
Yes
No
I understand that any conduct or pattern of conduct that would tend to disrupt, diminish, or otherwise jeopardize public trust in the City of Longview will result in dismissal.
Statement 3
*
-- Select One --
Yes
No
I understand that my volunteer assignment with the City of Longview may be terminated at any time.
Statement 4
*
-- Select One --
Yes
No
I understand that depending upon the nature of the volunteer assignment, the City of Longview may deem it necessary to obtain a Driver's License Record and/or a Criminal Conviction History and Wanted Information Reports on individuals volunteering for the City of Longview. I hereby consent to the City of Longview to make any requests for a Drivers License Record, a Criminal History Report, and/or a Wanted Information Report on me. I release, relinquish, and remise the City of Longview, its employees,agents, and representatives, from any and all causes of action or liability which I may have or which arise out of, or as a result of, the reports herein authorized. Furthermore, I understand that my failure to execute this informed consent will result in my not being further considered for employment or volunteerism.
Statement 5
*
-- Select One --
Yes
No
I have NOT been convicted and/or placed on probation for any criminal offense.
Statement 5 - Addendum 1
If you HAVE been convicted and/or placed on probation, please list date and nature of offense.
Previous Addresses
*
List any states you have lived in besides Texas and how long you resided there.
E-Signature
*
Date
Date
Continue
|
Go Back
Mentor Survey
This information will help us know more about you and allow us to match you with a Mentee that is compatible with you. Please fill this out as correct and honestly as you can.
Name
Ethnicity
Gender
Male
Female
Non-binary
Prefer not to answer
Marital Status
Spouse/Partner Name
Do you have children living at home? If so, what are their grades and schools?
Days that you could meet with your Mentee
*
Monday
Tuesday
Wednesday
Thursday
Friday
Weekends
Times that you could meet with your Mentee
*
Lunchtime
Evening
Other times during the School Day
Preferred School District
*
Preferred Campus
*
Which age group are you interested in working with?
*
Select all that apply
Elementary: Grades 1-5
Middle/JH: Grades 6-8
High School: Grades 9-12
Would you have any concerns about with any of the following children?
Select all that apply
Very active child
Child of a different race
Child with learning disability
Child with behavior problems
Child with ADHD
Overweight child
Child with emotional problems
How would you describe yourself?
*
Select all that apply
Outgoing
Friendly
Musical/Theatrical
High Energy
Athletic/Enjoys Sports
Outdoorsy/Enjoys Nature
Prefers Indoor Activities
Computer/Tech Enthusiast
Shy
Quiet
Laid Back
Other
Hobbies/Interests
*
Why would you like to become a mentor?
*
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
|
Go Back
* indicates a required field
Longview Public Library
Visit Longview
Longview Convention Complex
Animal Care and Adoption Center
Police Department
Fire Department
Parks and Recreation
Careers
Work With Us
Weather Alerts
Sign-up for Notifications
Agenda Center
Public Notices and Agendas
Coronavirus - COVID-19
Keep Yourself Safe
Government Websites by
CivicPlus®
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow