MENTOR APPLICATION

FAMILY ROOTS FOR LIFE, INC.

Children, Youth, and Family Services - Reunite. Reconnect. Restore.
MENTOR APPLICATION

Please complete the application in its entirety. The information you provide will help us match you with a mentee that has unique development/learning needs that most closely matches your experience and skills.
First and Middle Name*
First and Middle Name
Last Name*
Last Name
Mobile Phone Number*
Mobile Phone Number
Alternate Phone Number
Alternate Phone Number
Residence Address (Apartment/Suite)*
Residence Address
City State Zip Code*
City State Zip Code
E-mail Address*
E-mail Address
Drivers License #*
Drivers License #
Date of Birth*

MonthDayYear
Date of Birth
Social Security Number*
SSN
Race/Ethnicity:
Optional
Please briefly state why you want to be a mentor. Please include any personal qualities or experience developing others.*
VOLUNTEER ELIGIBILITY
Have you ever been convicted of a felony?*

YESNO
If yes, please provide details here:
Have your ever been accused of abusing or neglecting a child?*

YESNO
If yes, please provide details here:
EDUCATION
High School / Vocational / Trade
School most recently attended (Ed1)
Address
Street Address (Ed1)
City State Zip Code
City State Zip Code (Ed1)
Diploma: Yes / No
(Ed1)
From
Start Date (Ed1)
To
End Date (Ed1)
College / Trade School / Specialized Training / Other Education
Please list highest proficiency, special skills or other items that may contribute to your abilities. (Ed2)
Address
Street Address (Ed2)
City State Zip Code
City State Zip Code (Ed2)
From
Start Date (Ed2)
To
End Date (Ed2)
Degree: Yes / No
Degree (Ed2)
Other
Other (Ed2)
VOLUNTEER and/or WORK EXPERIENCE
Are you currently employed?

YESNO
Employer
1st Employer (E1)
Position/Title
Position/Title (E1)
Responsibilities
Responsibilities (E1)
Supervisor Name and Phone Number
Supvsr or Mgr (E1)
Start Date

MonthDayYear
Start Date (E1)
End Date

MonthDayYear
End Date (E1)
Reason for Leaving
Reason for leaving (E1)
Employer
2nd Employer (E2)
Supervisor Name and Phone Number (1)
Position/Title
Position/Title (E2)
Responsibilities
Responsibilities (E2)
Supervisor Name and Phone Number
Supvsr or Mgr (E2)
Start Date

MonthDayYear
Start Date (E2)
End Date

MonthDayYear
End Date (E2)
Reason for Leaving
Reason for leaving (E2)
Employer
3rd Employer (E3)
Position/Title
Position/Title (E3)
Responsibilities
Responsibilities (E3)
Supervisor Name and Phone Number
Supvsr or Mgr (E3)
Start Date

MonthDayYear
Start Date (E3)
End Date

MonthDayYear
End Date (E3)
Reason for Leaving
Reason for Leaving (E3)
BACKGROUND CHECK CONSENT
Are you willing to consent to a background check?*

YESNO
REFERENCES

Please provide three (3) character references:

(Applicant must provide one-relative and two non-relative references.)
First Name
1st Reference (R1)
Last Name
1st Reference (R1)
Relationship
Relationship (R1)
Company/School
Company/School (R1)
Phone Number
Phone Number (R1)
E-mail Address
E-mail Address (R1)
Do you agree to have references contacted? (R1)

YESNO
First Name
2nd Reference (R2)
Last Name
2nd Reference (R2)
Relationship
Relationship (R2)
Company/School
Company/School (R2)
Phone Number
Phone Number (R2)
E-mail Address
E-mail Address (R2)
Do you agree to have references contacted? (R2)

YESNO
First Name
3rd Reference (R3)
Last Name
3rd Reference (R3)
Relationship
Relationship (R3)
Company/School
Company/School (R3)
Phone Number
Phone Number (R3)
E-mail Address
E-mail Address (R3)
Do you agree to have references contacted? (R3)

YESNO
Mentor Applicant Disclaimer:

Volunteer Mentor Applicant understands that Family Roots for Life, Inc. is an Equal Opportunity Employer and is committed to excellence. In order to ensure this application is acceptable, please type and complete in its entirety in order for it to be considered.

Please complete each section EVEN IF you decide to attach a resume'. Be sure to also forward a current copy of your state-issued Texas Driver's License or state-issued identification.

My below electronic signature certifies that my answers are true and correct to the best of my knowledge. If this application leads to my eventual approved mentorship, I understand that any false or misleading information in my application or interview may result in the termination of my volunteer mentor relationship.
Signature certification*

Clear
Today's Date*

MonthDayYear
Today's Date
Any questions may be submitted to the below e-mail address:

info@familyrootsforlife.org
Website: www.familyrootsforlife.org

Inquiries: info@familyrootsforlife.org
Please verify that you are human*
Should be Empty:

FAMILY ROOTS FOR LIFE, INC.