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.
Format: (000) 000-0000.
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 (5 - 11)
Middle School (12 - 14)
High School ( 15 - 18)
Young Adult (18-24)
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.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
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.
*
Submit
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