There are two ways through which you can apply to become a Starfish Mentor. You can fill out the online form below or you can download the print version of the application and then resubmit either by fax, mail or e-mail.

When you have completed the print application to become a mentor, you may fax it to us at 317.955.7916, attention Tameka Boudaia. You can also email Tameka at tameka@starfishinitiative.org or call her at 317.955.7918.

All information will be kept confidential and required fields must be provided for this application to be considered. Mentor applicants must be college graduates.

Starfish Mentor Application
PERSONAL INFORMATION
First Name: *
Middle Name: *
Last Name: *
Email Address: *
Address:

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Home Phone:

### 		-
### 		-
####
Work Phone:

### 		-
### 		-
####
Cell Phone:

### 		-
### 		-
####
Preferred Method of Contact:
Birth Date *

MM 		/
DD 		/
YYYY
Gender: *
Race *
If other race, please specify:
Primary Language: *
If other language, please specify:
Primary Religion: *
Marital Status: *
If married, spouse's name:
Household Income: *
Income information is used for grant writing purposes and in no way affects the acceptance or declination outcome for a particular mentor.
 
EMPLOYMENT
Organization Name: *
Organization Address:

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Job Title/Position: *
Provide a Brief Description: *
Occupational Field: *
 Business 
 Education 
 Government 
 Health Care 
 Homemaker 
 Hospitality/Tourism 
 Other 
 Retired 
 Technology 
 Transportation 
If other field, please specify:
 
EDUCATION (Mentor applicants must be college graduates)
Highest Level of Education: *
Degree Major/Minor
Date Received:

MM 		/
DD 		/
YYYY
School Name: *
 
INTERESTS/MATCH PREFERENCE
Check all that apply!
General:
 Arts/Crafts 
 Shopping 
 Cooking 
 Fashion 
 Dance 
 Drama 
 Eating Out 
 Writing 
 Movies 
 Board Games 
 Computer Games 
 Video Games 
 Reading 
 Pets 
 TV 
 Travel 
Playing Sports:
 Baseball 
 Basketball 
 Cheerleading 
 Football 
 Golf 
 Gymnastics 
 Hockey 
 Lacrosse 
 Martial Arts 
 Soccer 
 Softball 
 Tennis 
 Track/Field 
 Volleyball 
 Wrestling 
 Other 
Watching Sports:
 Baseball 
 Basketball 
 Cheerleading 
 Football 
 Golf 
 Gymnastics 
 Hockey 
 Lacrosse 
 Martial Arts 
 Soccer 
 Softball 
 Tennis 
 Track/Field 
 Volleyball 
 Wrestling 
 Other 
Cultural Events:
 Theater 
 Concerts 
 Museums 
 Other 
Music:
 Listening to Music 
 Playing an Instrument 
 Singing 
 Other 
Outdoor Activities:
 Biking 
 Boating/Canoeing 
 Fishing/Hunting 
 Ice Skating 
 Rollerblading 
 Skateboarding 
 Walking 
 Skiing 
 Snowboarding 
 Hiking 
 Running 
 Other 
 
On a scale of 1-10 (1 = very uncomfortable / 10 = very comfortable), how would you feel meeting a Scholar or their family in an urban, inner-city neighborhood? *
 
Do you have any preferences regarding the Scholar you will be matched with (school they attend, ethnicity, spiritual/religious affiliation, etc...)?
 
How did you hear about Starfish? *
 
Please explain why you are interested in mentoring a Starfish Scholar: *





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814 N. DELAWARE STREET
INDIANAPOLIS, IN 46204
P: 317.955.7912
F: 317.955.7916

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