Mentorship Application

Mentorship Application
SECTION ONE: GENERAL INFORMATION
Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived at this address? ___ years (if less than five years, please list previous addresses below)
Date of Birth
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Alternate Contact (Name)
Alternate Contact (Telephone number with area code)
SECTION TWO: EMPLOYMENT INFORMATION
Occupation:
Employer Name:
Title:
Work Phone:
Fax Number:
Email:
Length of Employment: From __________ to ___________
Name of Supervisor:
Title:
SECTION THREE: BACKGROUND SCREENING
Will you agree to have Safe & Sound Hillsborough check your background through Federal and state agencies for criminal records and child abuse and neglect proceedings?

YesNo
Social Security Number (xxx-xx-xxxx)
Do you have a valid Driver's License?

YesNo
Driver's License Number
State Issued
Date Issued
Expiration Date
Have you ever been convicted of a crime?

YesNo
If yes, please explain
SECTION FOUR: MENTORING INFORMATION
Why do you want to be a mentor?
Do you have any previous experience volunteering, mentoring or working with youth?
Do you have any hobbies or special skills?
What support or resources would you need to be successful as a mentor?
As a youth, did you have a mentor? What was successful and challenging about being mentored?
Driver's License File Upload (Front & Back)

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Social Security Card File Upload

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Please read this carefully before signing:

By signing below, you attest to the truthfulness of all information listed on this application. You agree to let our program confirm all information listed and to conduct a federal and state criminal records check.

If selected, I will be a dedicated mentor. I agree to the time commitment to my mentee of one year. I will ensure that I maintain contact with my mentee, offer him/her support, and ensure his/her attendance to all Mentor/Mentee meetings and events.
Signature

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Mentorship Application

SECTION ONE: GENERAL INFORMATION

SECTION TWO: EMPLOYMENT INFORMATION

SECTION THREE: BACKGROUND SCREENING

SECTION FOUR: MENTORING INFORMATION