Mentorship Application Form
Mesa County Partners
Date
*
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Month
-
Day
Year
Date
Name
*
First Name
Last Name
Phone Number (Home/Mobile)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (Work)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender/Pronouns
*
Marital Status
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Spouse's Name
First Name
Last Name
Spouse's Age
Briefly describe your relationship with children.
*
How did you hear about Partners?
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Have you ever applied to be (or have been) an Adult Mentor before?
*
Please Select
Yes
No
If yes, please explain your history as an Adult Mentor
What are your past experiences with children/youth (e.g. teacher, parent, uncle etc.)
*
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Employment
Present Employer
*
Employer address
*
Employer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Length of Employment
*
Occupation
*
Supervisor Name
*
First Name
Last Name
Previous Employer #1
*
Previous Position #1
*
Years employed w/ employer #1
*
Previous Employer #2
Previous Position #2
Years employed w/ employer #2
Previous Employer #3
Previous Position #3
Years employed w/ employer #3
Do you have military experience?
*
Please Select
Yes
No
Date of discharge (leave blank for active service)
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Month
-
Day
Year
Date
Type of discharge
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Education
High School
*
Years attended
*
Graduated?
*
Please Select
Yes
No
No, I have my G.E.D.
Graduation Year
College / University #1
Years Attended College / University #1
Write 'still attending" if you are currently enrolled
Degree / Major
College / University #2
Years Attended College / University #2
Degree / Major
College / University #3
Years Attended College / University #3
Degree / Major
What is your highest degree attained?
*
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Health
How would you rate your personal health?
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Poor
Fair
Good
Excellent
Any physical limitations or special concerns?
*
Any known allergies?
*
Have you ever sought counseling or treatment for any reason?
*
Please Select
Yes
No
If so, when?
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Month
-
Day
Year
Date
If so, please explain
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Driving
Do you have a valid drivers license?
*
No
Yes (Please indicate the license state in the box below)
Driver's License Number
Do you have your own transportation?
*
Yes
No
If you don't have your own transportation, do you have access to transportation?
No
Yes (Please Describe)
Do you have current vehicle insurance as required by this state's law?
*
No
Yes
N/A
Have you ever been arrested or convicted of a DUI?
*
No
Yes (Please type the year below)
Have you ever lost your driver's license?
*
No
Yes (Please explain in the box below)
Have you ever been involved in an accident harmful of others?
*
No
Yes (Please explain in the box below)
By signing below, I agree I will promptly report to Partners any changes in my insurance coverage or drivers license status
*
Signature Date
*
-
Month
-
Day
Year
Date
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Legal History
Have you ever been a victim of a crime?
*
No
Yes (Please explain in the box below)
Have you ever been involved, investigated, and/or convicted of any assault?
*
No
Yes (Please explain in the box below)
Have you ever been involved, investigated, arrested, and/or convicted of a felony or any other offense?
*
No
Yes (Please explain in the box below)
When?
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Month
-
Day
Year
Date
Have you ever been involved, investigated, arrested and/or convicted of child abuse, neglect or sexual molestation of a minor?
*
No
Yes (Please explain in the box below)
When?
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Month
-
Day
Year
Date
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References
REFERENCE 1: List four REFERENCES (one present or past employer, one you have known for at least two years or more,). Each entry should include: Reference name, relationship to you, address, zip code, and phone number
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Reference 1
REFERENCE 2: Each entry should include: Reference name, relationship to you, address, zip code, and phone number
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Reference 2
Please list your interests, hobbies, and activities in which you are presently involved
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I understand that Partners will contact the above listed references, and any other persons deemed necessary to verify my qualifications to be an Adult Mentor. I agree to a Police and FBI check. I will provide Partners with: Central Registry Status, copy of my drivers license, copy of my Division of Motor Vehicle Record, and proof of car insurance. I understand that misrepresentation of personal information or history could result in termination or non-acceptance in the Partners program. I authorize Partners to disclose any information about me received by Partners during my application process or thereafter to any third persons whom Partners believes has a need to know the information, including but not limited to Partners staff, and potential Junior Partners and his or her parent or guardian. I also understand that Partners cannot guarantee the confidentiality of such information, given the number of participants involved, and the openness and configuration of the Partners' office. In addition I understand that Partner's reserves the right to refuse admission into the program. Accordingly, I waive and release Partners from any liability stemming from the intentional or unintentional disclosure of such information, to any third persons whomsoever.
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Signature Date
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Month
-
Day
Year
Date
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Setting Yourself Up for Success
I expect these two things of myself in the Partnership:
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I will expect these two things from my Mentee:
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These are two ground rules I will hold to and expect in our Partnership:
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What can you offer a troubled child?
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What are your strengths?
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What are your weaknesses
*
What attitudes and beliefs are of special importance to you?
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Other Comments and Concerns
*
Submit
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