Mentor1 Mentor Application

Mentor1 Mentor Application

This form is for those interested in being a Mentor for our Mentor1 program.
Full Legal Name*

First NameMiddle NameLast NameSuffix
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Ethnicity*

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhite or CaucasianOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Number*
Please enter a valid phone number.
Home Number*
Please enter a valid phone number.
Work Number*
Please enter a valid phone number.
Which phone number is your preferred contact?*

Cell PhoneHome PhoneWork Phone
Employer*
Job Title*
Length of Employment*
Education*

High School2 Year Degree4 Year DegreeAdvanced Degrees
Name of School(s) and Degree(s) obtained
How was Mentor1 brought to your attention?*
What motivated you to apply to be a mentor?*
Will you be able to meet with a student at least once a month during the school year?*

YesNo
What are your hobbies, special skills, or other interests?*
What do you like to do in your leisure?*
What other affiliations (e.g. service or volunteer organizations) do you have?*
What do you hope to gain from the Mentor1 experience?*
What do you hope your mentee gains from the mentoring experience?*
Do you have prior mentor experience*

YesNo
If Yes, please explain (Program Name(s) and Dates)
How many students would you like to mentor?*

12Other
Explain other:
Is there a particular student you would like to mentor?*

YesNo
Name of Student & Church he/she attends
Why do you want to mentor this specific student?
Are you willing to have a background check, including fingerprints?*

YesNo
List three people (non family members) who can serve as a character reference for you.
Reference # 1 Information
Reference #1 Name*

First NameLast Name
Relationship to Reference #1*
How long have you know Reference #1?*
Address for Reference #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number for Reference #1*
Please enter a valid phone number.
Email for Reference #1*
example@example.com
Reference #2 Information
Reference #2 Name*

First NameLast Name
Relationship to Reference #2*
How long have you know Reference #2?*
Address for Reference #2*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number for Reference #2*
Please enter a valid phone number.
Email for Reference #2*
example@example.com
Reference #3 Information
Reference #3 Name*

First NameLast Name
Relationship to Reference #3*
How long have you know Reference #3?*
Address for Reference #3*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number for Reference #3*
Please enter a valid phone number.
Email for Reference #3*
example@example.com
I certify that the information I have supplied is correct to the best of my knowledge. I grant permission for you to contact the references provided. I also understand and agree to the duties and requirements described in the Volunteer Duties and Requirements.
Signature*

Clear
Todays Date*

MonthDayYear
Date
Should be Empty:

Mentor1 Mentor Application

Reference # 1 Information

Reference #2 Information

Reference #3 Information