The following information
is used only to determine diversity of Street
Tech mentors/volunteers. Completion is optional. (Please check one)
American (not Hispanic)
Caucasian (not Hispanic)
Hispanic
Asian or Pacific Islander
American Indian
Other:
Age:
Are you a student?
Full Time
Part Time
No
Is it necessary to limit
your physical activity in any way? If yes,
what is your limitation or challenge?
Are you a licensed driver?
Yes No
Do you have a car?
Yes No
List previous mentoring
or volunteer experiences (volunteer, paid,
or educational) that would be helpful in
working with young adults and/or technology.
Activity
Organisation
Date
List any skills, hobbies,
or interests you have that might be helpful
in volunteering for Street Tech:
Are you able to fluently
speak, read or write any language other
than English?
How many hours a week and
on what days are you available to mentor/volunteer?
Are you available for weekly
face to face visits with your mentee/student
or do you prefer to be in contact by phone
and/or Email?
Available for visits
Available by phone
Available by Email
Individual to be notified
in case of Emergency:
Name
Relationship
Address
Tel No.
For further information
contact Joe McKinley at (510) 234-1300 ext.
2
2300 El Portal Dr, Suites F & G • San Pablo, CA 94806 • Tel:(510)234-1300 • Fax:(510)234-1330
2300 El Portal Dr, Suites F & G • San Pablo, CA 94806 • Tel:(510)234-1300 • Fax:(510)234-1330 