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:*

Elementary SchoolMiddle SchoolHigh School
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.*

YesNo
I understand that I will be required to complete the mentor program orientation and at least one training session during the academic year.*

YesNo
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.*

YesNo
Are you under current indictment or have a district/county attorney accepted any complaint for any of these offenses?*

YesNo
If you answered YES to any of the previous questions regarding criminal history, please explain below:
Educational Background *

Some High SchoolHigh School GraduateSome CollegeGraduate/Professional SchoolTechnical SchoolCollege GraduateDoctorate/PhD
Why do you want to become a mentor? *
What days of the week are you available to volunteer?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What is the best time(s) for you to volunteer?*

MorningsAfternoonsEveningsWeekends
How did you hear about Cultivating Leaders Mentoring Programs?*

Social MediaColleagueInternet SearchFriendFamily MemberCurrent/Previous Mentor
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*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Visionary Men Youth Mentoring Program

Volunteer Information

References

Required Signature