CUT Youth Employment Program MENTOR Sign-Up Form
Fill out the form carefully for registration
Your Name
First Name
Middle Name
Last Name
Birth Date
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Day
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Gender
Please Select
Male
Female
N/A
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
Format: (000) 000-0000.
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Employment History
Please provide your most recent employment information.
Employer:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dates of Employment
Position Held:
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Interview Questions
Please answer all of the following questions as completely as possible.
1. Why do you want to become a mentor?
2. Do you have any previous volunteering or working with youth? If so, please specify.
3. What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain.
4. Can you commit to participate in the CUTS mentoring program for a minimum of one year from the time you are matched with a youth?
5. Are you available to meet with a child eight hours per month and have contact at least once per week? Please explain any particular scheduling issues.
Yes
No
6. How would you describe yourself as a person?
7. How would your friends, family, and co-workers describe you?
8. Have you ever been arrested or convicted of a crime? If so, what are the circumstances?
Yes
No
9. Are you currently using any illegal drugs or controlled substances?
Yes
No
10. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? If so, please explain.
Type option 1
Type option 2
11. Have you ever been investigated or convicted of child abuse or neglect? If yes, please explain.
Yes
No
12. Have you ever been convicted of a DUI, driving while under the influence of alcohol? If yes, when and what were the circumstances?
Yes
No
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?
Yes
No
Are you willing to attend an initial mentor training session and two in-service training sessions per year after being matched?
Yes
No
I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship. Please initial below.
I agree to have a background check prior and fingerprinting done prior to the start of the mentoring relationship. Please initial below.
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
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