THRIVE Mentor Application Form

THRIVE Youth Mentor Application
Thank you for your interest in becoming a THRIVE Youth Mentor. To be a mentor
you must be 18+ and commit to 4 hours a month for 1 year.
Name of applicant

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Drivers License Number
Drivers License Number
Auto Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Languages Spoken
Gender:
Your Availability To Mentor
Morning (8am-12pm)
Afternoon (12pm-4pm)
Evening (4pm-9pm)
Do you have reliable transportation?
Do you prefer to be matched with:
I would like work with a child in:
Please write a brief statement on why you wish to be a mentor in the program:
Describe special interests/hobbies, which may be helpful in matching you with a mentee (e.g. cooking, crafts, career interests, chess, stamp collecting, sports, computers, art, needlepoint, speak multiple languages, music, painting, etc.)
Personal History
State the address where you have lived the last five years (begin with the most recent after your current address):
Dates:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide two personal references (other than family members):
1. Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Highest level of education achieved:
2. Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment History. Please provide two professional references:
1. Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to you:
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List the last three places of employment with the most recent first:
1. Company:
1. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
1. Job Title:
1. Dates employed:
1. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Company:
2. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2. Job Title:
2. Dates employed:
2. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Company:
3. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
3. Job Title:
3. Dates employed:
3. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Information Release

In applying to be a volunteer mentor, I understand that the THRIVE Youth Mentoring program routinely performs criminal and driving record checks of all volunteers. This check may be done on me if I electronically sign below. If I faily to sign, it may be grounds for rejecting me as a mentor.

I certifiy to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and subsequent mentor application forms, is grounds for dismissal.
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Thank you for be interested in helping the youth in Kittitas County!
Should be Empty:

THRIVE Youth Mentor Application

Your Availability To Mentor

Personal History

Thank you for be interested in helping the youth in Kittitas County!