CSN is seeking mentors of all backgrounds who are willing to give 3-5 hours each semester to guide the future of Nevada: our youth. Mentors must be 21 years of age, willing to provide information to conduct a criminal background report and able to participate in one mandatory training session. CONTACT INFORMATION First Name * Last Name * Email Address * Street Address * Street Address #2 City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Cell Phone Work Phone * Home Phone Gender * Male Female Non Binary Company * - Select -Bank of AmericaBank of NevadaBoyd Gaming PropertiesCaesars Entertainment & PropertiesCentury LinkCity of HendersonCity of Las VegasCity of North Las VegasClark CountyClark County School DistrictCollege of Southern NevadaCox CommunicationsMGM Resorts & PropertiesNevada Highway PatrolNevada State BankNevada State CollegeSands Corp & PropertiesSt. Rose Dominican HospitalsStations Casinos & PropertiesSW GasUniversity of Nevada Las VegasValley Bank of NevadaValley Hospital SystemWells Fargo BankOther Company (Other) * If your "Company" is not listed above, please enter it below: Job Title * EMPLOYEE DETAILS Department CCSD Employee Are you a CCSD employee? If yes, you will be prompted to enter information about CCSD. Yes No CCSD School Please provide the name of the school you work at: CSN Employee * Are you a CSN employee? If yes, you will be prompted to enter information about CSN. Yes No CSN School - None -AdministrationAdvanced & Applied TechnologiesApprenticeship StudiesArts & LettersBusiness Hospitality & Public ServicesCSN FoundationEducation Behavioral & Social SciencesHealth SciencesScience & MathematicsWorkforce and Economic Development CSN Campus * As a CSN Employee, which campus do you spend the most time at? West Charleston Campus Henderson Campus North Las Vegas Campus Water Street Other CREDENTIALS Professional Field * Professional Certifications List Degrees * Major or Specialty * Describe skills or training Other Volunteer Activity Referred By How did you year about the Nevada Promise Mentor Program? PREFERENCES We will pair mentors and students based on preferrences as much as possible, however, we ask that Mentors maintain flexibility as this may not always be possible. Preferred Campus West Charleston Campus Henderson Campus North Las Vegas Campus Water Street Other Days Preferred days to meet: Monday/Wednesday/Friday Tuesday/Thursday Saturday No Preference Times Preferred Times of day to meet: Mornings Afternoons Evenings Mentors can be paired with up to 10 students in one academic year. CSN recommends that each Mentor commit to no more than 3 to 4 students as a manageable number. Number of Students - Select -12345678910 REFERENCES REFERENCES 1 First Name * Last Name * Email * Phone * Profession * Relationship * REFERENCES 2 First Name Last Name Email Phone Profession Relationship AGREEMENT *ACKNOWLEDGEMENT AND BACKGROUND CHECK RELEASE: (All applicants must complete mandatory training and complete a background check. Please initial your approval to do so below) By submitting this form I agree to allow CSN to share my contact information with my Nevada Promise mentees and other relevant parties. I understand that when possible mentors will be matched to mentees based on career interests but due to the quantity of mentees, matching may need to be conducted on a random basis. Mentor Qualifications: The law that created the Promise Program requires all potential mentors to undergo a criminal background check. A person convicted of a felony cannot serve as a mentor. Mentors must be 21 Years of age. Mentors may not employ the person being mentored. Mentors may not be related by consanguinity or affinity within the third degree to the students being mentored. Mentors also may not be compensated for their service. Acknowledgement and Background Check Release I acknowledge that a criminal background check is required by Nevada law to participate as a Promise Program mentor. I authorize the College of Southern Nevada to work with a third party vendor to conduct a criminal background check. If for any reason I do not meet the background check requirements, the College of Southern Nevada will inform me in writing and will provide me with the information of the third party vendor so that I may contact them for further information. I agree to complete the mentor application and authorize the background check electronically. Initial #1 * Employees of identified and verified partner organizations that conduct criminal background checks as a condition of employment, may be exempt from submitting to an additional background check. Employers will be notified of the desire of employee to apply to the program and will certify their employment and background check. If my employer is one of the identified partners, I hereby authorize CSN to communicate with my employer to verify that I meet the requirements of criminal background check established for the Promise Program. I do so by electronically authorizing the verification with my initials below. Initial #2 *
