Name *

First Name

Last Name

Mobile Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Gender *

Female

Male

Prefer not to disclose

Race/Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Latino

Multi-Racial

Don't Know

Other

How did you hear about Imagine LA? *

Corporation/Business

Faith Community

Online (Google, Mentor.org, Golden, LA Works)

Civic/Nonprofit Group

Government/Public

Mentor Referral

Imagine LA Event Volunteering

Los Angeles County Employee Mentoring Program

Board Referral

Other

THE FOLLOWING QUESTIONS RELATE TO OUR WORKFORCE DEVELOPMENT PATHWAYS. PLEASE SELECT ALL CHECKBOXES THAT APPLY. IF NONE OF THE QUESTIONS APPLY TO YOU, PLEASE SELECT THE FINAL BOX INDICATING "NONE OF THE ABOVE."

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

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

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 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?

I DO NOT HAVE EXPERIENCE IN ANY OF THE ABOVE WORKFORCE PATHWAYS.

PLEASE SELECT ALL AGE RANGES YOU ARE COMFORTABLE MENTORING. SELECT ALL THAT APPLY.

5-10 years old

11-13 years old

14-18 years old

19-23 years old

24-29 years old

30-39 years old

40-49 years old

50+ years old

Do you have direct experience working with youth? Check box if YES.

Yes

No

Do you have direct experience working with individuals with intellectual or physical disabilities?

Yes

No

IN WHAT GEOGRAPHIC AREAS ARE YOU OPEN TO MENTORING SOMEONE? PLEASE SELECT ALL CHECKBOXES THAT APPLY.

Metro Los Angeles

South Los Angeles

West Los Angeles

San Fernando Valley

San Gabriel Valley

South Bay

Today's Date *

MM

DD

YYYY