Mentor Application

Visionary Men Youth Mentoring Program

Mentor Application Form
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Home Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Gender
Age
Race or Ethnicity
Employer
Occupation
Employer City & Zip Code
Email
example@example.com
Work Phone

Area CodePhone Number
Volunteer Information
Indicate your school level preference:
Write a brief statement on why you have chosen to participate in Cultivating Leaders mentoring programs?
What do you feel are the strengths (previous relevant volunteer experience, skillsets, etc.) you can bring to this program?
I understand that the mentoring program involves spending a minimum of one hour every week for the academic year with an assigned student.
I understand that I will be required to complete the mentor program orientation and at least one training session during the academic year.
Within the last 10 years, have you been convicted of a felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance.
Are you under current indictment or have a district/county attorney accepted any complaint for any of these offenses?
If you answered YES to any of the previous questions regarding criminal history, please explain below:
Educational Background
Why do you want to become a mentor?
What days of the week are you available to volunteer?
What is the best time(s) for you to volunteer?
How did you hear about Cultivating Leaders Mentoring Programs?
References

Please list three references:
REFERENCE #1
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
REFERENCE #2
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
REFERENCE #3
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Required Signature
In submitting this application to be a volunteer/mentor, I understand that Cultivating Leaders routinely request criminal and driving record checks of all volunteers for the position of mentor for which I am applying. All mentors must undergo a Federal Background Check. Prospective mentors are responsible for procuring the Federal Background Check and submitting the results to Cultivating Leaders. You may forward the copy for review and acceptance to:

Dr. Joe Rush
Founder/CEO
Cultivating Leader Inc.
135 Loblolly Court
Elloree, SC 29047

All records are kept confidential. If I fail to sign, it may be grounds for rejecting you as a mentor.

I certify to the best of my ability that the information provided in this application is true and accurate. I also understand that misinformation knowingly provided here and on subsequent mentor application form, is ground for dismissal.
Signature
Date

MonthDayYear
Date
Should be Empty:

Visionary Men Youth Mentoring Program

Volunteer Information

References

Required Signature