NAPF Programs: Youth Outreach: Youth Conference: Mentor Application Form

Mentor Application Form

The movement to abolish nuclear weapons spans over 60 years. Millions of people around the world have engaged in some form of activism on the issue over the decades. Their diverse experiences, e.g., successes, shortcomings, and missed opportunities, serve as valuable learning opportunities for emerging leaders working on nuclear issues. We invite veteran activists to mentor a young leader selected for "Think Outside the Bomb."

Mentor - Eligibility and Responsibility

Mentors must be at least 25 years of age.
Mentors are accessible and responsive whether by email or telephone.
Mentors support participants' efforts to implement their action plans after the gathering.
Mentors devote at least 1 hour per week through August 2006.

Are you interested in mentoring? Please complete the application below.

Mentor Personal Profile

First Name:
Last Name
E-Mail:

Street Address:
City:		State / Province:
Zip / Postal Code:		Country:

Home Phone:		Cell Phone:
Gender:		Ethnic Background:

How did you hear about "Think Outside the Bomb"?


	Please send me regular updates about the Nuclear Age Peace Foundation's Youth Outreach Initiative and the Foundation's monthly e-newsletter, the Sunflower.

Mentor Professional Background

What is your Current Profession?

Employment Status:
Self-Employed
Full Time
Part Time
Retired

Organization / Company Name:
Street Address:
City:		State / Province:
Zip / Postal Code:		Country:

How Long have you been with this Organization?
Less than 1 Year
1-5 years
6-10 years
11-15 years
More than 16 years

Please describe your role in your current organization (50 words or less)?


Educational Background:
Degrees:
Year Obtained:
Majors / Fields :

Mentor Volunteer Background

Describe your previous activism experience:


Which issues interest you most?
Nuclear Weapons		Nuclear Energy
Nuclear Waste		Progressive Philanthropy
Environment		Counter Recruitment
Arts & Activism		Public Education
Racial Reconciliation		Other:

Do you have previous mentoring experiance?
Yes No

If yes, please describe in 50 words or less:


Mentor Availability

Are you willing to commit to mentoring through to August 2006?
Yes No

Please estimate your availability per week:
Less than 1 hour
1-2 hours
3 hours or more

How often do you check your e-mail?
Multiple times a day
A couple of times a week
Once a week
Once a month

Are you interested in participating in at least part of the actual event, August 15-21, 2005?
Yes No

How often are you willing to communicate with students?
2 or more times a week
Once a week
Once every 2 weeks
Once a month