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
Date of Birth

MonthDayYear
Date
Ethnicity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Which phone number is your preferred contact?
Employer
Job Title
Length of Employment
Education
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?
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
If Yes, please explain (Program Name(s) and Dates)
How many students would you like to mentor?
Explain other:
Is there a particular student you would like to mentor?
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?
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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
Todays Date

MonthDayYear
Date
Should be Empty:

Mentor1 Mentor Application

Reference # 1 Information

Reference #2 Information

Reference #3 Information