R&R BecomingHIM™ Mentor Interest & Screening Form

R&R BecomingHIM™ Mentor Interest & Screening Form

Complete this form to express interest—submission does not guarantee placement; applicants are screened, trained, and matched based on program needs and youth safety.
Contact Information
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Background
Current Employer / Occupation
Job Title
Organization / Church / Community Affiliation
Highest Education Level
Languages Spoken

Other
Military / Veteran Status
How did you hear about R&R / MAN UP?
Mentoring Interest
Why do you want to become a mentor?
Describe any prior mentoring, coaching, or youth work experience.
Which age ranges are you comfortable mentoring?
Preferred mentoring format
What interests, skills, or topics can you share?

Other
What qualities do you believe make a good mentor?
Availability
Days available for mentoring meetings
Preferred meeting times
Preferred meeting frequency

Other
Estimated length of commitment
Can reliably attend meetings and R&R events
Youth Support Scenarios
Which youth support areas are you comfortable helping with?

Other
How would you respond if a mentee disclosed a serious safety concern?
I confirm I am willing to follow R&R reporting, confidentiality, communication, and youth-safety policies.
Screening & Safety
Have you ever been convicted of or pled guilty or no contest to a criminal offense other than minor traffic violations?
If yes, please explain
Have you ever been investigated, disciplined, terminated, or asked to leave a children or youth-related role due to misconduct or boundary concerns?
If yes, please explain
Please confirm the following commitments
References
Reference 1 Full Name

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

First NameMiddle NameLast Name
Reference 2 Relationship
Reference 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Email
example@example.com
Matching
Preferred mentee age range

Other
Preferences or limitations we should consider when matching
What do you hope a young person gains from being mentored by you?
Agreement
Certification
Typed signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Acknowledgment of verification
Agreement to safeguarding requirements
Should be Empty:

R&R BecomingHIM™ Mentor Interest & Screening Form

Contact Information

Background

Mentoring Interest

Availability

Youth Support Scenarios

Screening & Safety

References

Matching

Agreement