The FARM Mentor Program Application
Must be 18 or older
The FARM is a mentoring program that leverages the use of animals and activities in nature to help students and Christian adults enter into long term relationships.
Contact Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
Phone Number
*
-
Area Code
Phone Number
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Male
Female
Marital Status
Married
Single
Emergency Contact
Name
*
First Name
Last Name
Relationship
*
Emergency Contact Phone
*
-
Area Code
Phone Number
History Profile
Occupation
*
Employer
Number of Years
Do you have any training or background in working with children who have experienced trauma?
*
Yes
No
If you answered yes above, briefly describe your experience.
Did you experience trauma as a child?
*
Yes
No
Criminal Background
If your records have been expunged pursuant to applicable law, you are not required to answer yes to the following questions. If you are unsure whether to answer yes, we strongly suggest that you answer yes and fully disclose all incidents.
Have you ever been convicted of or pleaded guilty to any crimes (including crimes of record which have been expunged and pleas of 'no contest'), including municipal, state and federal?
*
Yes
No
Have you ever been placed on probation, received a Suspended Execution, Suspended Sentence or Suspended Imposition of Sentence for any offense involving a minor child (a child under 18), or been placed on ANY local, state, or federal sexual registry?
*
Yes
No
Have you ever been sued in a civil court of law where the allegations in the suit involved illegal, inappropriate, or sexual conduct or contact with a minor child?
*
Yes
No
Have you ever been subject to any court order involving any sexual, physical or verbal abuse including but not limited to any domestic violence or civil harassment injunction or protective order?
*
Yes
No
Have you ever resigned, been terminated or been asked to resign from a position, whether paid or as a volunteer, due to a complaint(s) of sexual, physical or verbal abuse of minors?
*
Yes
No
Education
High School Name
Date of Graduation
College School Name
Date of Graduation
Other (Post grad) Name & Degree
Reference #1 - Name
*
First Name
Last Name
Reference # 1- Email
*
example@example.com
Reference # 1-Phone Number
*
-
Area Code
Phone Number
Reference #2 - Name
*
First Name
Last Name
Reference # 2- Email
*
example@example.com
Reference # 2-Phone Number
*
-
Area Code
Phone Number
Reference #3 - Name
*
First Name
Last Name
Reference # 3- Email
*
example@example.com
Reference # 3-Phone Number
*
-
Area Code
Phone Number
Personal/Spiritual Profile
Church Name (You presently attend)
*
Have you committed your life to the Lord Jesus Christ?
*
Yes
No
Describe yourself in a group setting.
List three strengths you have in leading children/young adults.
List three weaknesses you have in leading children/young adults.
I understand that I will be required to submit to a background check as a condition of acceptance as a volunteer, and that unsatisfactory results, refusal to cooperate, or any attempt to affect the results of these background checks will result in me being removed as a volunteer or volunteer applicant.
I hereby certify that all of the information provided by me in this Application (or in any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that falsification, misrepresentation or omission of any facts in these documents may (or will) be cause for the denial of acceptance as a volunteer, or immediate removal as a volunteer, regardless of the timing or circumstances of discovery.
I have carefully read the above Application and this Acknowledgment and Release and know and understand its contents.
*
Yes, I agree
Print Name
*
Signature (use mouse or finger)
Submit
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