Apply as an Instructor Name First Name Last Name Address City State Zip Email Phone D.O.B Gender Male Female Are you a student Yes No School If you are volunteering, are you doing so as part of a class or school requirement? Yes No Where did you learn about Us? Do you have any experience working with youth or Tutoring experience? Yes No Please list any skills/strengths you have. REFERENCES: To provide a safe and positive environment for the students in our program, it is important to obtain adequate information from each applicant. Please answer the following questions to assist in this process. Any information you provide will be kept confidential. Have you ever been arrested for a criminal offense, excluding minor traffic violations? Yes No Have you ever ben accused, arrested or convicted for sexually-related crimes? Yes No Have you ever been accused, arrested or convicted for any substance abuse-related crimes? Yes No Please give the name and phone number of three current references, one personal (excluding relatives) and two professional, who would be able to provide information related to employment, volunteer work and personal history. Name Name Name Relationship Relationship Relationship Phone No. Phone No. Phone No.