Mentor Application

Thank you for your interest in becoming an Amachi mentor! Please complete this application to determine your eligibility for the program. Should you be approved, your responses will also help us match you with a suitable mentee. All information will be kept strictly confidential.

Amachi Pittsburgh reserves the right to decline any applicant at any time in the application process without reason or disclosure.

Mentor Information

First Name *This question is required.

Last Name *This question is required.

If you have a preferred name or nickname, please list it here.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

If you speak a language other than English, please specify:

Do you currently attend a congregation or adhere to a religious practice? *This question is required.

If yes, please specify. *This question is required.

If married or in domestic partnership, what is your partner's name? *This question is required.

Are there other people living in your household? *This question is required.

Please list all member's of your household.
Select "Add Another" for each household member

Name

Age

Relationship

Do you expect to undergo changes, such as the following, within the next year? Please check all that apply. *This question is required.

If you said other, please specify. *This question is required.

Contact Information

Home Address *This question is required.

Apt/Suite

City *This question is required.

Zip *This question is required.

Email Address *This question is required. This question requires a valid email address.

Primary Phone Number *This question is required. Please provide a 10-digit phone number including area code.
Enter numbers only. Formatting such as dashes will be added as you enter your phone number.