Student Mentor Application

Contact Information
Mentor Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
A confirmation email will be sent to this address once application is submitted.
How do you prefer to be contacted?*

Preferred Location
Please indicate if you have a preference in the school you will be assigned to mentor.
Location Assignment Options*
Preferred School
Please indicate your preference in which school you mentor a student. You may enter a first and second choice.
School (first choice)*
School (second choice)*
Preferred Day
Please indicate if you have a preference in day to mentor a student. You may enter a first and second choice.
Day (first choice)*
Day (second choice)*
Preferred Time
Please indicate if you have a preference in time to mentor a student during school hours. You may enter a first and second choice.
NOTE: school hours vary with elementary schools typically in session between 8 a.m. - 3 p.m. and middle and high schools typically in session between 7:30 a.m. - 2:30 p.m.
Time (first choice)*
Time (second choice)*

Tell us more!
Employment*
List your current employer(s) or employment status (i.e. retired, stay-at-home parent, etc.).
Interests*
Describe any special interests which may be helpful in matching you and your mentee.
Acknowledgement*
By clicking below, I agree that I am able to meet with my mentee for a half hour each week over the course of the entire school year, during school hours and on school grounds.

I also agree to complete a mandatory orientation to understand the Dubuque Community School District Student Mentoring Program, which requires me to sign a Confidentiality Agreement, Code of Conduct, Mentor Agreement and Social Media Agreement.

I understand that a background check is required and must be completed before mentoring may begin.
I agree.

FOR MORE INFORMATION

Carlos Pittman
Student Support Liaison
cpittman@dbqschools.org
563/552-3069

Because the safety of our students is of the utmost importance, we require background checks of all non-employees involved in school programs.

To begin, review the volunteer guidelines and download the necessary forms included in the Non-Employee Background Check packet.

Non-employee Background Check packets are also available at each school building and at the district administrative offices located at 2300 Chaney Road, Dubuque, Iowa 52001.

Student Mentor Application

Contact Information

Preferred Location

Preferred School

Preferred Day

Preferred Time

Tell us more!