STY Volunteer Application

SupporTeen Youth, Inc.

Volunteer Application
SECTION ONE: GENERAL INFORMATION
Full Name *

First Name Middle Name Last Name
Current Address *

Street Address

Street Address Line 2

City State

Zip Code
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email Address *
example@example.com
SECTION TWO: EMPLOYMENT INFORMATION
Employer Name
Occupation *
Title
Work Phone Number

Area Code Phone Number
Length of Employment
Name of Supervisor
SECTION THREE: Background Screening

(this information is kept confidential and secure)
Will you agree to supply SupporTeen Youth, Inc. with a background check and also allow them to check through federal agencies for criminal record, child abuse, and neglect proceedings? *

Yes No
Have you ever been convicted of a crime? *

Yes No
If "Yes", please explain:
SECTION FOUR: REFERENCES
Reference 1:

Please list the names of three character references with phone and/or email address. Please list minimum of two non-relatives you have know for at least a year.
Name *

First Name Middle Initial Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Reference 2:
Name *

First Name Middle Initial Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Reference 3:
Name *

First Name Middle Initial Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
SECTION FIVE: MENTORING INFORMATION
Why do you want to be a mentor? *
Do you have previous experience volunteering, mentoring, or working with youth and families? *
Do you have a special skill, hobby, or training that you can share with youth and families? *
How did you hear about us? *
Please read this carefully before submitting:

By submitting below, you attest to the truthfulness of all information listed on this application. You agree to let our staff confirm all information listed and conduct a federal and state criminal record check.

I understand the programs rules, regulations, and responsibilities for becoming a volunteer. If submitted I will follow the rules of the program and be a dedicated mentor/volunteer.
Signature

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SupporTeen Youth, Inc.