First Name

Last Name

Email Address

Phone Number

Date of Birth (MM/DD/YYYY)

Gender GenderFemaleMale

Street Address

Apt Number

City

State

Zip

Emergency Contact Name (First and Last)

Emergency Contact Relationship

Emergency Contact Phone Number

Are you Hispanic or Latino? Are you Hispanic or Latino?YesNo

What languages do you speak?

Race (Check all that apply) Race (Check all that apply) White Black or African American American Indian and Alaska Native Asian Native Hawaiian and Other Pacific Islander Other

What is your availability? (Check all that apply) What is your availability? (Check all that apply) Mondays 2-6PM Tuesdays 2-6PM Wednesdays 2-6PM Thursdays 2-6PM Fridays 2-6PM Saturdays 9-12PM Other

Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance? Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance? Yes No

Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in the previous question? Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in the previous question? Yes No

I hereby grant and authorize permission to Operation Exodus and its affiliates to use my photos and/or videos for their respective websites, newsletters, social media, and/or educational and promotional materials. In giving this consent, I understand that my name and identity may be revealed therein or by descriptive text or commentary. I hereby grant and authorize permission to Operation Exodus and its affiliates to use my photos and/or videos for their respective websites, newsletters, social media, and/or educational and promotional materials. In giving this consent, I understand that my name and identity may be revealed therein or by descriptive text or commentary. By checking, I have read and agree to the photo release form.

As a mentor of Operation Exodus, I understand the mission of Exodus which states: launching NYC Latino Youth to college and lives of excellence through educational opportunities and transformational relationships. I agree to abide by the policies and procedures. I understand that I will be volunteering at my own risk and that the organization, its employees and affiliates, cannot assume any responsibility for any liability for any accident, injury or health problem which may arise from any volunteer work I perform for the organization. I agree that all the work I do is on a volunteer basis and I am not eligible to receive any monetary payment or reward. I understand that Operation Exodus routinely performs criminal and driving record checks of all volunteers. This check may be done on me if I agree below. If I fail to agree, it may be grounds for rejecting me as a volunteer. As a mentor of Operation Exodus, I understand the mission of Exodus which states: launching NYC Latino Youth to college and lives of excellence through educational opportunities and transformational relationships. I agree to abide by the policies and procedures. I understand that I will be volunteering at my own risk and that the organization, its employees and affiliates, cannot assume any responsibility for any liability for any accident, injury or health problem which may arise from any volunteer work I perform for the organization. I agree that all the work I do is on a volunteer basis and I am not eligible to receive any monetary payment or reward. I understand that Operation Exodus routinely performs criminal and driving record checks of all volunteers. This check may be done on me if I agree below. If I fail to agree, it may be grounds for rejecting me as a volunteer. By checking, I have read and agree to the organization policy and terms.

Any additional comments?