Mentor Application
Please allow 10-15 minutes to complete the application.
Type a question
Mentor Profile Information
Are you a new Mentor, or a returning Mentor?
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New
Returning
Mentor Applicant Full Name
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First Name
Last Name
Suffix
Preferred Name
Preferred Contact Number
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Mobile
Work
Home
Home Number
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Mobile Number
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Work Number
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Preferred Primary Email
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Personal
Work
Alternate
Personal Email
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Work Email
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Alternate Email
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Primary Street Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mentor Personal Information
Birthdate
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Month
-
Day
Year
Social Security Number
Marital Status
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Please Select
Single
Married
Divorced
Separated
Widowed
Other
If Married..Wedding Anniversary
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-
Month
-
Day
Year
Date
Spouse's Full Name
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First Name
Last Name
Number of Children
Mentor Education History
High School Graduated From
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Please Select
Berkley HS
Deer Valley
DeWitt
Dwright Rich
East Lansing
Eastern
Eaton Rapids
Everett
Florida School
Grand Ledge
Haslett
Holt
Holt/Blended Learning
Home Schooled
Lansing Charter
Life Tech Acad.
Martin Luther
Marvin E. Beakman
Mason
Okemos
Sexton
Washington Woods
Waverly
Wexford
Windemere
Woodcreek
WPCA
Other
If Other, which High School:
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Year Graduated
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College/University/Technical Vocation combo
College/University/Technical Training #1 Name
Year Graduated School #1
College/University/Technical Training #2 Name
Year Graduated School #2
College/University/Technical Training #3
Year Graduated School #3
Mentor Employment Information
Occupation
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Current Employer
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Length of Employment
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May we contact current employer?
Yes
No
Employer Number
Work/Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work address combo
Positions of other employment for the past three year (most recent first). Be sure to list: 1) Employer 2) Position 3) Length of Employment for each job held
More Mentor Profile Information
Men's Shirt Size
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Please Select
S
M
L
XL
2X
3X
4X
Valid Driver's License?
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Please Select
Yes
No
Drivers License / State ID Number
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State Issued
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Do you have your own personal reliable transportation
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Please Select
Yes
No
If Yes, do you have valid vehicle insurance?
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Please Select
Yes
No
If No, do you have access to transportation?
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Please Select
Yes
No
Are you willing to have a complete background check conducted?
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Please Select
Yes
No
Have you ever been arrested, convicted and/or sentenced of a crime?
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Please Select
Yes
No
If yes, please explain the circumstances.
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Interview Availability
When are you available for an interview?
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Monday, Morning
Monday, Afternoon
Monday, Evening
Tuesday, Morning
Tuesday, Afternoon
Tuesday, Evening
Wednesday, Morning
Wednesday, Afternoon
Wednesday, Evening
Thursday, Morning
Thursday, Afternoon
Thursday, Evening
Friday, Morning
Friday, Afternoon
Friday, Evening
Saturday, Morning
Saturday, Afternoon
Saturday, Evening
Sunday, Morning
Sunday, Afternoon
Sunday, Evening
Interview Questions
How did you hear about The Turning Point of Lansing?
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Why are you interested in becoming an elder of The Turning Point of Lansing?
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What experience do you have with youth?
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What are your expectations about being an elder?
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What unique experiences do you bring to The Turning Point of Lansing?
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What attitudes and beliefs are of special importance to you?
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Are you related to any program participants, if so what is your relationship?
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Releases and Commitments
ELDER POLICIES AND PROCEDURES - LINKBROKEN https://secureservercdn.net/166.62.112.219/2n9.abb.myftpupload.com/wp-content/uploads/2021/09/TTPL-Elder-Orientation-Packet-090921.pdf
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PRIVACY ACT STATEMENT I understand that all forms and information obtained from me and about me will be held in confidence by The Turning Point of Lansing. Only my application is accessible to me and all other information becomes the property of The Turning Point of Lansing. The Turning Point of Lansing will not release, unless required by law, information from the volunteer file to outside sources without my written approval other than verification that I am a volunteer. I understand that certain information such as Name, Address and Employment may be released to program participants’ parents. In addition, periodically volunteer files are audited for the purpose of program evaluation by the Executive Director of The Turning Point of Lansing and Board of Directors, which will uphold the volunteer’s confidentiality.
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ELDER LIABILITY RELEASE I understand and agree that I will be the one actually spending time with the mentees in the program, and that I must exercise care in supervising the mentees while we are together. I also understand and agree that I am not a Turning Point of Lansing agent, and the Turning Point of Lansing does not retain any power to control how these activities are conducted except to require these activities to be conducted in the State of Michigan. I, therefore, agree that The Turning Point of Lansing will not be liable for, and I agree to hold The Turning Point of Lansing harmless from any and all liability, causes of action and losses imposed on it in any way relating to or arising out of this mentoring agreement, including, but not limited to, liability for personal injuries, whether the liability, cause of action, or loss is caused by my negligence, or The Turning Point of Lansing negligence or otherwise. I further release The Turning Point of Lansing from any and all liability, claims, demands or actions or causes of action whatsoever arising out of any damage, loss or injury I might incur while participating in any of the activities contemplated by this mentoring agreement, whether such damage, loss, or injury is caused by the negligence of The Turning Point of Lansing, its officers, agents, servants, employees or otherwise.
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AUTHORIZATION OF PERSONAL RELEASE For the period of one year from the execution of this form I do hereby authorize a release of all said records concerning myself to any duly authorized agent(s) of The Turning Point of Lansing, whether the said records are of a public, private or confidential nature.The intent of this authorization is to give my consent for full and complete disclosure of information from any person or agency to include: educational institutions; records maintained by the National Personnel Records Center and the U.S. Veteran’s Administration; County, State or Federal Law Enforcement Agencies; employment and pre-employment records, including background reports, efficiency ratings and complaints or grievances filed by me or against me; psychiatric or psychological and social history/assessment records, wherever they may be maintained; and records pertaining to previous volunteer experience.I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability as a The Turning Point of Lansing elder. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release The Turning Point of Lansing from any and all liability which may be incurred as a result of collecting such information.A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an originalsignature.I have read and fully understand the contents of the “Authorization for Release of Personal Information” and certify that all belowlisted information is correct.
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ACKNOWLEDGMENT I certify that the information included in this application is entered is true and accurate to the best of my knowledge. I UNDERSTAND THAT WITHHOLDING INFORMATION REQUESTED ON THIS APPLICATION OR GIVING FALSE INFORMATION MAY MAKE ME INELIGIBLE FOR ACCEPTANCE INTO THE TURNING POINT OF LANSING OR SUBJECT TO DISMISSAL AS AN ELDER. WITH THIS IN MIND, I CERTIFY THAT THE ABOVE STATEMENTS ARE CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I FURTHER UNDERSTAND THAT THIS APPLICATION WILL BE RETURNED IF I HAVE NOT PROVIDED ALL THE INFORMATION NECESSARY TO PROCESS THE APPLICATION.
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Submission Date
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