4-H Positive Youth Development Mentor Application

Step 1 of 2

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County*
Phone*
Email*
Enter Email Confirm Email
Organizational Affiliation*

Example: Orono Public Library
What grade level(s) of youth do you prefer working with?*
- Select All
- Kindergarten, 1, 2
- Junior Grades: 3, 4, 5
- Intermediate Grades: 6, 7, 8
- Senior Grades: 9, 10, 11, 12
Please explain why you're interested in a 4-H volunteer position:*
Previous work or volunteer experience, skills, training, education:*
Hobbies and interests:*
How did you hear about the 4-H volunteer program?*

References
List two persons not related to you who have a definite knowledge of your qualifications. Current faculty at your university are acceptable as references. Include complete addresses and email for each.
Reference 1: Name*
First Last
Reference 1: Email
Enter Email Confirm Email
Reference 1: Phone
Reference 1: Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Reference 2: Name*
First Last
Reference 2: Email
Enter Email Confirm Email
Reference 2: Phone
Reference 2: Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
May we contact other references suggested to us in the course of contacting the references listed above?*
- Yes
- No
Please note: information received from any references will be considered as a part of your application.
Have you ever been convicted of any crime other than a minor traffic violation?*
- Yes
- No
If yes, please describe:
I authorize contact of listed references. I understand that misrepresentation or omission of facts requested is cause for non-appointment or termination as a Cooperative Extension volunteer. I agree to abide by the expectations of Cooperative Extension and to fulfill the volunteer responsibilities to the best of my ability.
Volunteer Signature*

Please type your first and last name; understand that typing your name constitutes a legal signature confirming that you acknowledge and agree to the above statement.
Comments
This field is for validation purposes and should be left unchanged.

4-H Positive Youth Development Mentor Application

4-H Positive Youth Development Mentor Application

Step 1 of 2

References