Created for a Purpose Mentor Application

Ladies With Purpose Mentoring Program Mentor Application
Date

MonthDayYear
Date
SECTION ONE: GENERAL INFORMATION
Name
Address
Apt.
City
State
Zip
Date of Birth

MonthDayYear
Date
Home Phone
Cell Phone
E Mail
example@example.com
This can be a cell, email, or person
example@example.com
Bilingual

Yes/Indicate Languages/ Written/ Spoken:No
Yes/Indicate Languages/ Written/ Spoken:
Name
Phone Number
Single

Marital Status:MarriedDivorcedSeparatedChildren:YesNoN/A
SECTION TWO: EMPLOYMENT INFORMATION
Occupation
Employer Name
Title
Work phone
Fax
Email
example@example.com
From
to
Name of Supervisor
Title
SECTION THREE: Background Screening (this information will be kept confidential and secure)
Do you have a valid Driver's License?

YesNo
State Issue
Date Issue

MonthDayYear
Date
Expire Date

Have you ever been convicted of a crime?YesNoIf "Yes", please explain:
Expire Date

MonthDayYear
Date
"Yes", please explain
SECTION FOUR: MENTORING INFORMATION
How did you hear of our program?
Why do you want to be a mentor?
Do you have any previous experience volunteering, mentoring, or working with youth?
Do you have any hobbies or special skills?
What support or resources would you need to be successful as a mentor?
As a youth, did you have a mentor? What was successful and challenging about being mentored?
What do you hope to accomplish as a Mentor?
How would you describe your personality? Check all that apply.
Encouraging

TalkativeLaid BackSeriousFunnyDo you commit to a minimum of four (at least 1 Face to Face) contacts per month with the selected candidate? No YesFriendly and outgoing
Life of the Party

MotivationalReservedQuietOther
What do you do in your free time?

Watch MoviesListen to MusicPlay Video Games
Play Sports

GardenReadOther:
Please describe any special interests that may be helpful in matching you and your mentee (i.e. stamp collecting. roller skating, computers, football, music, painting, etc.)
Please prioritize the following criteria you would prefer in a mentee.
Similar personal interest's
Other
Additional information or comments
Please list the names, addresses, and phone numbers of two personal character references, plus one employer reference. Please list only nonrelatives you have known for at least a year.
Name
Years Known
Address
City
State
Zip
Phone
Relationship
Years Known
Address
City
State
Zip
Phone
Relationship
Years Known
Address
City
State
Zip
Phone
Relationship
Please read this carefully before signing: 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. 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.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: