KCPS Success Mentor Application

Personal Information

First Name *This question is required.

Last Name *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Street Address *This question is required.

Apt/Suite

City *This question is required.

Zip *This question is required.

Have you lived at this residence less than 5 years? *This question is required.

Please list the address(es) of your previous residence, if current residence is less than five years:

Email Address *This question is required. This question requires a valid email address.

Preferred Phone Number *This question is required.

Secondary Phone Number

Present Occupation

Employer

Job Title

Street Address

Apt/Suite/Office

City

State

Zip

Phone Number with Ext.

First and Last Name of Supervisor

May we contact you at work?

KCPS may be contacting your employer as a reference. Is there any reason that you would not want us to contact your employer?

If yes, please explain:

Please specify the name of the organization or affiliation:

How did you learn about KCPS mentoring opportunities?

Below is a list of the current Success Mentors Launch sites. Please be mindful of school bell times when selecting your school preference and availability. Please let us know if your availability is outside normal school hours.

KCPS Success Mentor Application

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