STY Mentor Application

SupporTeen Youth, Inc.

Mentor 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?
Select One

Yes No
Have you ever been convicted of a crime? If "Yes", please explain:
SECTION FOUR: REFERENCES
Reference 1:

Please list the names and phone numbers of two character references, plus one employer reference. Please list only non-relatives you have know for at least a year.
Name *

First Name Middle Initial Last Name
Phone Number *

Area Code Phone Number
Reference 2:
Name *

First Name Middle Initial Last Name
Phone Number *

Area Code Phone Number
Reference 3:
Name *

First Name Middle Initial Last Name
Phone Number *

Area Code Phone Number
SECTION FIVE: MENTORING INFORMATION
Why do you want to be a mentor?
Do you have previous experience volunteering, mentoring, or working with youth?
Do you have hobbies and special skills?
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 puritan confirm all information listed and conduct a federal and state criminal record check.

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

SupporTeen Youth, Inc.