Date:   

Name:    Social Security #:    Driver's License #:   

Home Address:    City:    State:

Home Phone #:    Work Phone #:   

Employer:    Title:    Supervisor's Name:

Have you ever been convicted of a crime? No Yes

If "yes', please explain:   

Do you object to our agency running a background check on you? No Yes

Mentoring Information

Why do you want to be a mentor?   

Can you meet with a child as often as our program requires?    

Do you have any previous experience volunteering or working with youth?   

Are you able to meet with your mentee on Tuesday nights in a two hour time frame from 5-7pm?   

Do you have any hobbies or special skills?   

Would you prefer to be matched with a child from a specific grade level?   

Would you be willing to work with a child who has disabilities?   

Would you be willing to be matched with two children at a time?   

Can you speak any other languages?   

References

Please list the names, addresses, and phone numbers of three people you would like to use as character references (please list only people you have known for at least a year):

Name:   

Address:    City:    State:    Zip Code:

Phone #:    Relationship:

Name:

Address:    City:    State:    Zip Code:

Phone #:    Relationship:

Name:

Address:    City:    State:    Zip Code:

Phone #:    Relationship:

Please read this carefully before signing:

Our program appreciates your interest in becoming a mentor to a child. By signing below, you attest to the truthfulness of all information listed on this application. You agree to let our program confirm all information listed and to conduct a federal and state criminal records check.

I have read and understand the program's rules, regulations, and responsibilities for becoming a mentor. I agree to the time commitment of hours/month and months.

Signature:_____________________________

Date:_________________________________