TAKE STOCK IN CHILDREN MENTOR APPLICATION
This form is used to apply to become a mentor with Take Stock in Children.
Equal Opportunity Policy
Take Stock in Children is an equal opportunity organization and complies with all applicable federal, state, and local non-discrimination laws. Take Stock in Children strictly prohibits and does not tolerate discrimination against students, mentors, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including pregnancy), sexual orientation, gender (including gender nonconformity and gender identity), marital status, age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All Take Stock in Children employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. Take Stock in Children will reasonably accommodate qualified individuals with a disability as required by law. Take Stock in Children will also, where appropriate, provide reasonable accommodations for an individual's religious beliefs or practices. Finally, no one will be subject to, and Take Stock in Children prohibits, any form of discipline, reprisal, intimidation, or retaliation for good faith reports or complaints of incidents of discrimination of any kind, pursuing any discrimination claim, or cooperating in related investigations.
SECTION ONE - PERSONAL INFORMATION
Name
*
First Name
Middle Name
Last Name
Salutation
Salutations
Please Select
Mr.
Mrs.
Ms.
Dr.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Phone Number
*
Please enter a valid phone number.
Phone Type*
*
Home
Cell
Work
Email*
*
Email addresses allow us to contact the greatest number of people most efficiently at a minimal cost. Be assured that email addresses will be used for professional communications only.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender*
*
Please Select
Female
Male
Race*
*
Please Select
American Indian/Native American
Asian
Black/African American
Multiracial
Pacific Islander/Hawaiian
White
Other
Ethnicity: Are you of Hispanic, Latinx, or Spanish origin?*
*
Yes
No
Age*
*
Please Select
18-30
31- 40
41-50
51-60
61+
Marital Status
Please Select
Single
Married
Divorced
Widowed
Do you have children? If yes, please indicate the number of daughters & sons, as well as their ages
SECTION TWO - EMPLOYMENT
Employment Status*
*
Employed (Please fill out employer below)
Unemployed (Please fill out previous employer below)
Retired (Please fill out previous employer below)
Employer Name*
*
Current or Previous Employer
Current Employer
Previous Employer
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Phone Number
*
Please enter a valid phone number.
Your Title/Position
*
Employment Start Date
*
-
Month
-
Day
Year
Department
SECTION THREE - SCHOOL PREFERENCE & AVAILABILITY
Check the area(s) you would like to mentor in.*
*
NORTH (Rivera Beach, PBG & Jupiter area)
CENTRAL (West Palm Beach to Lake Worth area)
SOUTH (Boynton Beach to Boca Raton area)
WEST (Wellington to Royal Palm Beach area)
Belle Glade and Pahokee area
List any specific schools you would like to be assigned to mentor at.
SECTION FOUR - EDUCATION
Highest Level of Education Achieved*
*
Please Select
High School
Associate Degree
Bachelor's Degree
Graduate or Professional Degree
Some College
Techinical/ Vocational Certificate
Other
Prefer Not to Answer
If degree, which field?
Are you a first-generation college graduate?*
*
Please Select
Yes
NO
Are you currently enrolled in any education or training program? If yes, please specify.
Please indicate any other languages spoken
Please specify any volunteer experience or training you have had working with children in the past
SECTION FIVE - SKILLS/INTERESTS
In addition to mentoring, check one or more ways you would be willing to volunteer
*
Donate Products/Services
School Supply Drive
Special Events
Other
If other, please specify how you would be willing to volunteer.
Please indicate any other skills you would like to share with our agency and/or students.
Do you have any specific training or experience in the following areas? (Check all that apply)
College Admissions / Applications
Communication
Financial Literacy / Financial Aid
Health & Wellness
Leadership
Life Skills
Persistence / Resiliency
Self Advocacy
Study Skills
Social / Business Etiquette
Time Management
Which of the following activites do you enjoy participating in or watching? (Check all that apply)
Sports
Handicrafts
Outdoor Life
Mechanics/Science
Literature
Pop Culture (Movies, TV, etc.)
Music
Collecting
If you selected any of the boxes above, please explain.
Please list any clubs or professional organizations you are a member of
I am interested in becoming a mentor because (check all that apply):
*
I would be a positive role model
I have the time to give
I overcame difficulties growing up and would like to help someone else.
I think I have the personality and abilities to be a good mentor
I am interested in making a difference in the life of a child
I believe in the value of mentoring
I wish I had had a mentor when I was a teenager
How would you describe your communication style?
*
Friendly and outgoing
Usually wait to be approached by someone new
Reserved until I get to know someone new
Are there any particular challenges you would prefer not to handle as a mentor?
*
Yes
No
If yes, please explain:
Is there anything else you would like us to know about you?
How did you hear about Take Stock in Children?*
*
Please Select
Business/Company Partnership
Event
Friend/Colleague
Internet Search
Print
Radio
School
Social Media
TV
Are you a graduate of the Take Stock in Children Program?*
*
Please Select
Yes
No
If yes, what year did you graduate and from what county?
SECTION SIX - BACKGROUND INFORMATION
Do you have any objection to undergoing a background check in order to become a mentor?*
*
No
Yes
Do you have any felony charges? Convictions?*
*
No
Yes
Do you have any misdemeanor charges? Convictions?*
*
No
Yes
Personal References
Please provide the names, phone numbers, and complete mailing address of three people we can contact.
Personal Reference #1
Personal Reference 1 Name
*
First Name
Last Name
Personal Reference 1 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Reference 1 Phone Number
*
Please enter a valid phone number.
Relationship*
*
Years Known*
*
Personal Reference #2
Personal Reference 2 Name
*
First Name
Last Name
Personal Reference 2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Reference 2 Phone Number
*
Please enter a valid phone number.
Relationship*
*
Years Known*
*
Personal Reference #3
Personal Reference 3 Name
*
First Name
Last Name
Personal Reference 3 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Reference 3 Phone Number
*
Please enter a valid phone number.
Relationship*
*
Years Known*
*
If you are currently employed, please print the name and address of your work supervisor. If employed less than 6 months, the previous employer.
First Name
Last Name
Supervisor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor's Phone
Please enter a valid phone number.
SECTION SEVEN - LEGAL/RELEASES
Signature
*
First Name
Last Name
Signature
*
First Name
Last Name
Signature
*
First Name
Last Name
SECTION EIGHT - MENTOR POLICY ADHERENCE AGREEMENT
Digital Signature
Submit
Should be Empty: