757 We Care Mentor Application

TOGETHER WE CAN MENTOR APPLICATION

All information is held strictly confidential. This form must be completely filled out. The information is vital to your acceptance and possible placement as a volunteer.
Full Legal Name*

First NameMiddle NameLast Name
Last four digits of your Social Security Number*
Background Check Requirement

Your Full Social Security number may be required separately to obtain the criminal background check from a third party. There is a $29 Mentor Sponsorship Fee upon submission of this application.
Please also upload a current photo of yourself (headshot).*

Upload a File

Cancelof
Gender*

MaleFemale
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long have you lived in [state]? Years and Months*
If you have lived in [state] for less than five years, list your complete addresses for the last five years:*
E-mail*

Confirmation Email
Phone Number:*

Area CodePhone Number
Occupation*
Name of Employer*
Dates of Employment*
Emergency Contact*
Relationship *
Phone (Emergency Contact)*
T-Shirt Size*

Adult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-Large
Have you received certification in any of the following?*

CPRFirst AidLife GuardNurseEMTCounseling or TherapyNone
Do you have previous background or training in working with children?*

YesNo
If yes, in what way?
Were you a victim of abuse, neglect, or abandonment as a minor?*

YesNoYes, but I would prefer to discuss this in person
If yes, please clarify
MEDICAL CONCERNS
Do you have any medical conditions or concerns, driving issues or concerns, or are you taking any medications that you believe could prevent you from being an effective volunteer that we need to know about in order to help you be effective?*

NoYes
Please Describe:
Education
High School Name*
Date of Graduation*
College
College Major
Date of Graduation
Other Education
Personal References* (required for first time volunteers only) No former employers or relatives.

Please notify your references that they will be contacted via email or phone.
Reference #1 - Name*

First NameLast Name
Reference #1 - Phone*

Area CodePhone Number
Reference #1 - Email*

Confirmation Email
Reference #2 - Name*

First NameLast Name
Reference #2 - Phone*

Area CodePhone Number
Reference #2 - Email*

Confirmation Email
Reference #3 - Name*

First NameLast Name
Reference #3 - Phone*

Area CodePhone Number
Reference #3 - Email*

Confirmation Email
Personal Profile
Why do you want to become a mentor?*
What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain.*
Can you commit to participate in the 757 We Care mentoring program for a minimum of one year?*
Are you available to meet with a child five hours per month and have contact at least once per week? Please explain any particular scheduling issues.*
How would you describe yourself as a person?*
How would your friends, family, and co-works describe you?*
Have you ever been arrested or convicted of a crime? If so, what were the circumstances?*
Have you ever used illegal drugs? If so, what substances were used and how often?*
Are you currently using illegal drugs or controlled substances?*
Do you drink alcoholic beverages? If so, what and how often?*
Have you ever been convicted of a DUI, driving while under influence of alcohol? If yes, when and what were the circumstances?*
Do you use tobacco products? If so, what and how often?*
Have you ever received treatment for alcohol or substance abuse? If yes, please explain.*
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?*

NoYes
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?*

NoYes
Are you willing to communicate regularly and openly with program staff, provide monthly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program?*
Are you willing to attend an initial mentor training session and two in-service training sessions per year after being matched?*
Please read the following carefully before signing:

757 We Care Mentoring Program appreciates your interest in becoming a mentor.
I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.*

AgreeDisagree
I understand that 757 We Care Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.*

AgreeDisagree
I agree to allow 757 We Care Mentoring Program to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.*

AgreeDisagree
Please attach a valid copy of your driver's license.*

Browse Files

Cancelof
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
Signature*

TOGETHER WE CAN MENTOR APPLICATION

Background Check Requirement

MEDICAL CONCERNS

Education

Personal References* (required for first time volunteers only) No former employers or relatives.

Personal Profile

Please read the following carefully before signing: