Mentor Application

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Mentor Application

Cadet Information

Mentor Information
Mentor's Name:
Gender:  
Ethnic Race:
Date of Birth: // (mm/dd/yyyy)
Social Security #: (xxx-xx-xxxx)
Marital Status:        
Drivers License #:
Auto Insurance?:    

Occupation Information
Occupation:
Employer:
Employment:    

Contact Information
Home Phone:
Work Phone:
Cell Phone:
Pager:
Fax:
Email:

Address
Address 1:
Address 2:
City:
State: Zip:
County:

Authorization For Release of Information and Records
In accordance with the Privacy Act of 1974 or other applicable law, I hereby authorize and consent to the releases of information and records bearing on my personal history, arrest, and convictions, if any, to special agents of the Department of Defense or Oklahoma Military Department. Upon request, a copy of this signed statement may be furnished to the school, present or former employer, criminal justice agency, or other person furnishing such information or record. This information will be used for the purpose of determining our eligibility as a participant with the Thunderbird Youth Academy, and will be held in the utmost confidence.