Mentor Application

Mentor Application

Complete this form to apply for the Love In Action Foundation Career Development & Mentorship Program.
Personal Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Method of Contact
Professional Information
Job Title
Industry/Career Field
Years of Professional Experience
Professional Certifications, Licenses, and Skills
Highest Level of Education
Professional Website
Experience Working With Youth
Have you previously mentored young people?
Organization
Length of Service
Describe your mentoring experience
Availability
Available Start Date

MonthDayYear
Date
Preferred Meeting Frequency
Preferred Meeting Method
Days Available
Times Available

Hour Minutes

AM/PM Option
Background Screening
Are you willing to complete a background check?
Have you ever been convicted of a felony?
If yes, please provide an explanation.
Are you legally eligible to work in the United States?
References
Reference #1 Name

First NameMiddle NameLast Name
Reference #1 Relationship
Reference #1 Company
Reference #1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference #1 Email
example@example.com
Reference #2 Name

First NameMiddle NameLast Name
Reference #2 Relationship
Reference #2 Company
Reference #2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference #2 Email
example@example.com
Mentor Expectations Agreement
Be a positive role model
Maintain professional boundaries
Communicate respectfully
Keep student information confidential
Attend required mentor orientation
Commit to regular participation
Notify the Foundation if you can no longer serve
Final Questions
What strengths would you bring as a mentor?
Is there anything else you would like us to know?
Electronic Signature
Typed Full Name

First NameLast Name
Electronic Signature
Date

MonthDayYear
Date
Should be Empty:

Mentor Application

Personal Information

Professional Information

Experience Working With Youth

Availability

Background Screening

References

Mentor Expectations Agreement

Final Questions

Electronic Signature