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 21+ and commit to 4 hours a month for 1 year.
Name of applicant*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number *
Drivers License Number *
Drivers License Number *
Auto Insurance Company*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Languages Spoken*
Gender:*

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.
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.
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.
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.
Relationship to you:*
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.
1. Job Title:*
1. Dates employed:*
2. Company:*
2. Phone Number*
Please enter a valid phone number.
2. Job Title:*
2. Dates employed:*
3. Company:*
3. Phone Number*
Please enter a valid phone number.
3. Job Title:*
3. Dates employed:*
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*

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Today's Date*

MonthDayYear
Date
Thank you for be interested in helping the youth in Kittitas County!
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THRIVE Youth Mentor Application

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