ACTION, Inc. Mentor Application
Personal Information
Date
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Month
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Day
Year
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Name
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First Name
Last Name
DOB
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Month
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Day
Year
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Email
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example@example.com
Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Race
Please provide employment information for your four most recent employers, with most recent position held first.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please answer all of the following questions as completely as possible.
Why do you want to become a mentor?
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Do you have any previous experience volunteering or working with youth? If so, please specify.
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What qualities, skills, or other attributes do you feel you have that would benefit a student in our program? Please explain.
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Can you commit to participate in the ACTION, Inc mentoring program for a minimum of one year from the time you are matched with a youth? Our program is typically 6-12 months.
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Yes
No
Describe your general health. Are you currently under a physician’s care or taking any medications? If so, please explain.
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How would you describe yourself as a person?
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How would your friends, family, and co-workers describe you?
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Have you ever been arrested or convicted of a crime? If so, what were the circumstances?
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Have you ever been convicted of a DUI, driving while under the influence of alcohol? If yes, when and what were the circumstances?
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Are you currently using any illegal drugs or controlled substances?
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Yes
No
Have you ever received treatment for alcohol or substance abuse? If yes, please explain.
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No
Have you ever been treated or hospitalized for a mental disorder? If yes, please explain.
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No
Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? If yes, please explain.
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No
Are you willing to communicate regularly and openly with program staff, provide monthly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program?
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Yes
No
Are you willing to attend an initial mentor training session and two in-service training sessions per year after being matched?
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Yes
No
Are you willing and able to spend at least one hour per week (per youth) on our program to ensure youth’s success? More hours may be required, depending on the needs of your match.
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Yes
No
By signing below, I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.
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Clear
By signing below, I understand that ACTION, Inc’s mentoring program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.
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Clear
(optional) By signing below, I agree to allow ACTION, Inc to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
Clear
By signing below, I understand I must return all of the following completed items if selected to be a mentor, and that any incomplete information will result in the delay of the mentoring relationship: Copy of your valid driver’s license; Proof of auto insurance; Information Release form; Personal References Form; Survey form; background check
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Clear
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
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Clear
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