Partners Mentoring Application

Mentorship Application Form

Mesa County Partners
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Phone Number (Home/Mobile)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Work)
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex / Gender
Marital Status
Spouse's Name

First NameLast Name
Spouse's Age
Child 1's Name

First NameLast Name
Child 1's Age
Child 2's Name

First NameLast Name
Child 2's Age
Child 3's Name

First NameLast Name
Child 3's Age
Briefly describe your relationship with children.
How did you hear about Partners?
Have you ever applied to be (or have been) an Adult Mentor before?
If yes, please explain your history as an Adult Mentor
What are your past experiences with children/youth (e.g. teacher, parent, uncle etc.)
List any volunteer and/or community experiences you have been involved with:
Present Employer
Employer address
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Length of Employment
Occupation
Supervisor Name

First NameLast Name
Previous Employer #1
Previous Position #1
Years employed w/ employer #1
Previous Employer #2
Previous Position #2
Years employed w/ employer #2
Previous Employer #3
Previous Position #3
Years employed w/ employer #3
Do you have military experience?
Date of discharge (leave blank for active service)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of discharge
High School
Years attended
Graduated?
Graduation Year
College / University #1
Years Attended College / University #1
Degree / Major
College / University #2
Years Attended College / University #2
Degree / Major
College / University #3
Years Attended College / University #3
Degree / Major
What is your highest degree attained?
How would you rate your personal health?
Any physical limitations or special concerns?
Are you taking any medications on a regular basis?
Any known allergies?
Have you ever sought counseling or treatment for any reason?
If so, when?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If so, please explain
Do you have a valid drivers license?

Yes (Please indicate the license state in the box below)
Driver's License Number
Do you have your own transportation?
Car License Plate Number
If you don't have your own transportation, do you have access to transportation?

Yes (Please Describe)
Do you have current vehicle insurance as required by this state's law?
Insurance Company
Policy Number
Have you ever been arrested or convicted of a DUI?

Yes (Please type the year below)
Have you ever lost your driver's license?

Yes (Please explain in the box below)
Have you ever been involved in an accident harmful of others?

Yes (Please explain in the box below)
By signing below, I agree I will promptly report to Partners any changes in my insurance coverage or drivers license status
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you ever been a victim of a crime?

Yes (Please explain in the box below)
Have you ever been involved, investigated, and/or convicted of any assault?

Yes (Please explain in the box below)
Have you ever been involved, investigated, arrested, and/or convicted of a felony or any other offense?

Yes (Please explain in the box below)
When?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you ever been involved, investigated, arrested and/or convicted of child abuse, neglect or sexual molestation of a minor?

Yes (Please explain in the box below)
When?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
REFERENCE 1: List four REFERENCES (one present or past employer, two friends you have known for at least two years or more, and one relative). If you have recently been or currently are in counseling or therapy/treatment, please substitute the name of your therapist for one of your friends references. Each entry should include: Reference name, relationship to you, address, zip code, and phone number
Reference 1
REFERENCE 2: Each entry should include: Reference name, relationship to you, address, zip code, and phone number
Reference 2
REFERENCE 3: Each entry should include: Reference name, relationship to you, address, zip code, and phone number
Reference 3
REFERENCE 4: Each entry should include: Reference name, relationship to you, address, zip code, and phone number
Reference 4
Please list your interests, hobbies, and activities in which you are presently involved
I understand that Partners will contact the above listed references, and any other persons deemed necessary to verify my qualifications to be an Adult Mentor. I agree to a Police and FBI check. I will provide Partners with: Central Registry Status, copy of my drivers license, copy of my Division of Motor Vehicle Record, and proof of car insurance. I understand that misrepresentation of personal information or history could result in termination or non-acceptance in the Partners program. I authorize Partners to disclose any information about me received by Partners during my application process or thereafter to any third persons whom Partners believes has a need to know the information, including but not limited to Partners staff, and potential Junior Partners and his or her parent or guardian. I also understand that Partners cannot guarantee the confidentiality of such information, given the number of participants involved, and the openness and configuration of the Partners' office. In addition I understand that Partner's reserves the right to refuse admission into the program. Accordingly, I waive and release Partners from any liability stemming from the intentional or unintentional disclosure of such information, to any third persons whomsoever.
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I expect these two things of myself in the Partnership:
I will expect these two things from my Junior Partner:
These are two ground rules I will hold to and expect in our Partnership:
What can you offer a troubled child?
What are your strengths?
What are your weaknesses
What attitudes and beliefs are of special importance to you?
Other Comments and Concerns
Should be Empty:

Mentorship Application Form