Teen TrUSt Mentor Application
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Birthday
*
-
Month
-
Day
Year
Date
Please list all food allergies:
*
T-shirt size
*
Adult XS
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL
Adult XXXL
Gender
*
Male
Female
Emergency Contact
*
First Name
Last Name
Emergency Contact's Phone Number
*
Please enter a valid phone number.
Relationship to Emergency Contact
*
How did you hear about our mentoring program?
*
Tell us about yourself -- work, hobbies, how others would describe you, etc.
*
Do you have any experience with children?
*
Yes
No
If yes, please describe your experience with children.
What qualities, abilities, and/or attributes do you have that would benefit a child facing abuse or neglect?
*
Were you a victim of abuse, neglect, or abandonment as a minor?
*
Yes
No
Please clarify, if needed.
Have you ever had an order of protection filed against you?
*
Yes
No
Have you ever been arrested for a criminal offense?
*
Yes
No
Have you ever looked at pornography featuring minors?
*
Yes
No
Have you ever left or been asked to leave a role within an organization due to a concern regarding inappropriate conduct?
*
Yes
No
Have you ever committed or been accused of any act involving the physical, sexual, or emotional harm of another person?
*
Yes
No
Have you ever been the subject of a DCFS investigation or are currently under investigation by DCFS?
*
Yes
No
Have you ever had any kind of relationship with a minor or vulnerable adult that has brought sexual gratification to yourself?
*
Yes
No
Are you dependent on any substance (other than prescription drugs) that you could not go without during a four hour time period?
*
Yes
No
Is there any circumstance or pattern in your life, or engagement in any behavior, which would compromise the integrity of Teen TrUSt Mentoring program or make it inappropriate for you to serve as a role model with our children?
*
Yes
No
Reference #1 Name
*
First Name
Last Name
Reference #1 Email
*
example@example.com
Reference #1 Phone Number
*
Please enter a valid phone number.
Reference #2 Name
*
First Name
Last Name
Reference #2 Email
*
example@example.com
Reference #2 Phone Number
*
Please enter a valid phone number.
Reference #3 Name
*
First Name
Last Name
Reference #3 Email
*
example@example.com
Reference #3 Phone Number
*
Please enter a valid phone number.
Do you understand that a background check will be run on you by Mission Church to verify your eligibility to serve as a mentor?
*
Yes
No
Please attach a recent photo of yourself. If you are having difficulty doing so, email it to teencamptrust@gmail.com.
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Is the information contained in this application correct to the best of your knowledge?
*
Yes
No
Signature
*
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