MENTOR APPLICATION
Date:
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Month
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Day
Year
Name:
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First Name
Middle Name
Last Name
Address:
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Street Address
Apartment Number
City
State / Province
Postal / Zip Code
Phone Number:
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-
Area Code
Phone Number
Preferred Pronouns
Email Address:
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Social Security Number:
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Date of Birth:
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Month
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Day
Year
Age:
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1. Who referred you to STRIVE Initiatives to become a Mentor?
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2. Why are you interested in becoming a Mentor?
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3. Do you have previous experience being a Mentor? If so, please explain.
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4. Are you currently providing mentoring services for another agency? If so, please explain.
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5. Do you have previous experience working with formerly incarcerated individuals? If so, please explain.
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6. What qualities, skills or attributes do feel you have that would benefit a Mentee? Please explain.
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7. Are you available to meet with a Mentee in person?
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8. How would you describe yourself as a person?
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9. Are you willing to communicate regularly and openly with program staff and provide monthly information regard your mentoring activities?
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Yes
No
10. Are you willing to attend ongoing Mentor training sessions and meetings?
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Yes
No
11. Are you currently on any type of legal supervision (County Probation, State Parole, etc.)?
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Yes
No
What type of supervision and through what agency?
Who is your Probation Officer or Parole Agent?
When do you complete your current sentence?
REFERENCES
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Rows
Name
Phone Number
Relationship
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Signature
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Date
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Month
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Day
Year
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