Mentor Application
Legal Name
First Name
Last Name
Preferred Name
First Name
Last Name
Preferred pronouns
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best way to contact you
Please Select
Text
Email
Phone call
Race/Ethnicity
American Indian or Alaska NativenBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteSome other race
Asia
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Are you Hispanic or Latino?
Yes
No
Do you have reliable transportation?
Yes
No
Why do you want to be a mentor?
What do you hope to gain from mentoring?
Have you ever mentored or worked with youth before? If yes, explain.
Do you have any mental health concerns that could impact your ability to mentor safely and reliably?
*
Yes
No
If yes, explain
Have you experienced a major trauma or loss in the last year?
*
Yes
No
If yes, explain
Do you currently use substances (alcohol/drugs) in a way that could interfere with mentoring?
*
Yes
No
If yes, explain
Have you ever been involved in an incident related to violence, aggression, or safety concerns?
*
Yes
No
If yes, explain
Have you ever been the subject of a child abuse or neglect investigation?
*
Yes
No
If yes, explain
Do you feel confident maintaining boundaries with a youth and their family?
*
Yes
No
"I understand and agree to follow all SEOYM safety guidelines, including maintaining appropriate boundaries with youth and families."
*
Agree
Do you have a valid driver's license?
Yes
No
Do you have current auto insurance?
Yes
No
Are you willing to consent to a background check?
*
Yes
No
Have you ever been convicted of a misdemeanor or felony?
*
Yes
No
If yes, explain
Are there any legal issues, past or pending that we should be aware of?
Yes
No
Are you currently a registered sex offender?
*
Yes
No
Which SEOYM program(s) are you interested in?
Community-based mentoring
Youth in Leadership (YiL)
CLI:MB
Bobcats & Buddies
The Forge @ HVCRC
No Preference
Preferred age group
Preferred gender to mentor (if any)
Availability (days/times)
Comfort level with LGBTQ+ youth
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable , 5 is Very comfortable
Comfort level with youth with disabilities
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable , 5 is Very comfortable
Comfort level with youth involved with CPS
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable , 5 is Very comfortable
Comfort level with youth experiencing behavioral challenges
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable , 5 is Very comfortable
Comfort level with trauma-informed communication
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable , 5 is Very comfortable
Read the following acknowledgements:
*
I understand that completing this form does NOT guarantee acceptance.
I attest that all information provided is true and complete.
I agree to abide by SEOYM mentor policies, including child safety and mandatory reporting laws.
I agree to participate in an interview, orientation, and training.
Signature
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