Volunteer_form_test

First Name

Last Name

Mobile phone (optional)

Send me email updates

Send me text messages

Address (Street, City, State, Postal code)

Email Type

What is your date of birth? (please enter as MM/DD/YYYY)*

Gender

T-shirt size

What race/ethnicity best describes you?

How did you hear about us?

Company/Employer*

Employment Status

Group/Organization Affiliation (e.g., faith-based organization, civic group, etc.)*

What's the highest level of education you've completed?

If bilingual, what language do you speak?

What are some of your interests/hobbies?*

How would your friends, family, and coworkers describe you if asked?*

Have you been a Nurse, Medical Asst, Phlebot., Physician Asst, Midwife, EKG Tech, Occupational Therapist, Pharmacy Asst, Health Info Tech, Hospital Admin, Community Health Worker, Mental Health Professional or another role in the health services industry?

Have you worked for UPS, FedEx, USPS, DHL or another logistics company as a Package Handler, Driver, Manager or Executive?

Have you operated your own home day center, been a teacher at a childcare facility or managed a child care facility? We are looking for Pre-K and early elementary teachers too!

Have you been a Case Manager, Case Management Supervisor, Outreach Worker, run a foster youth program or a homeless services agency or any other social services role? Do you have your MSW?

Have you ever bartended, been a server, been a cook or a chef? Have you started or run a restaurant, hotel or food truck? Have you ever started your own food or beverage company?

Have you ever worked for a tech start up, been a coder, been a project manager for a studio, worked on a film set or performed any role in the film and tv industry?

Have you ever been an office manager, been an executive asst., or managed administrative work in a government or corporate setting?

I do not have experience in any of the above workforce pathways.

Please list ALL age ranges you are comfortable mentoring (e.g., 5-10, 11-13, 14-18, 18-21, 24-29, 30-39, 40-49, 50+)

What are your means of transportation?*

Do you have experience working with children? Check box if "YES".

Do you have experience working with individuals with intellectual or physical disabilities? Check box if "YES" *

I'm open to mentoring someone in METRO/DOWNTOWN LA.

I'm open to mentoring someone in SOUTH LA.

I'm open to mentoring someone in WEST LA.

I'm open to mentoring someone in the SAN FERNANDO VALLEY.

I'm open to mentoring someone in the SAN GABRIEL VALLEY.

I'm open to mentoring someone in the SOUTH BAY.

Why do you think you'll make a great Imagine LA Mentor?

I, the applicant, hereby confirm that the information entered in this form is true, complete and accurate. (Enter your full name)

Date of Application

For more information about L.A. Works R.S.V.P., click here.

Volunteer Match Date

Graduation End Date

*****Affiliation - OLD / EVERYTHING BELOW IS NO LONGER IN USE, 6/1/20*****

Reference 1 Name*

Reference 1 Email*

Reference 1 Phone*

Reference 2 Name*

Reference 2 Email*

Reference 2 Phone*

Are You Bilingual?

Are you comfortable working with individuals with intellectual or physical disabilities? Check box if "YES" *

What type of mentor role are you interested in taking on?

What age would you like to work with?

I understand that Imagine LA is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.*

Yes, I understand

Total Volunteer Hours