Name of Applicant
*
First Name
Last Name
Occupation
*
Highest Educational Attainment
*
Are you an employee of any of the following, FBI, Secret Service, CIA or police department.
*
Yes
No
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Will you agree to have Y-KNOT Inc. check your background through federal and state agencies for criminal records and child abuse and neglect proceedings?
*
Yes
No
Days Available
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Number of Hours Available Per Week
*
0-1
1-2
2-3
3-4
4-5
5 or more
Age Preference
*
Elementary
Middle School
High School
Other
Interest and Hobbies
*
Reading
Sports
Music
Visual Arts
Travel
Poetry
Electronic Games
Politics
What best describes you?
*
Outgoing
Funny
Intuitive
Reserved
Vibrant
Passionate
Extrovert
Introvert
Do you have any health limitations?
*
Yes
No
Is there any characteristic in a mentee that you may be uncomfortable handling? Please specify.
*
Can you be a mentor for more than one person at the same time?
*
Yes
No
References - Please list the names, addresses, and phone numbers of two personal character references.
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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 understood the program’s rules, regulations, and responsibilities for becoming a mentor. If selected I will follow the rules of the program and be a dedicated mentor. I agree to the time commitment to my mentee of 10 hours a month for 12 months.
*
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