Mentor / Staff Application

MENTOR/ STAFF APPLICATION

All information is held strictly confidential. This form must be completely filled out. The information is vital to your acceptance and possible placement as a volunteer.
Full Legal Name *

First Name Middle Name Last Name
I am interested in volunteering *

Mentor Safety Companion
Last four digits of your Social Security Number *
Your Full Social Security number may be required separately to obtain the criminal background check from a third party. A photo I.D. (preferably Drivers license, Passport etc.) will be required to be shown at the interview to verify that your photo and name match the name on this application and background check.
Please also upload a current photo of yourself (headshot).
Gender

Male Female
Current Age *
Marital Status *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

How long have you lived in [state]? Years and months *
If you have lived in [state] for less than five years, list your complete addresses for the last five years:
E-mail *

Confirmation Email
Phone Number: Best one to contact you *

Area Code Phone Number
Occupation *
Name of Employer *
Number of Years At current employer *
Emergency Contact *
Relationship *
Phone (Emergency Contact) *
T-Shirt Size

Adult Small Adult Medium Adult Large Adult X-Large Adult XX-Large
Have you received certification in any of the following?

CPR First Aid Life Guard Nurse EMT Counseling or Therapy
Do you have previous background or training in working with children who have been abused or neglected?

Yes No
If yes, in what way?
Were you a victim of abuse, neglect, or abandonment as a minor?

Yes No Yes, but I would prefer to discuss this in person
If yes, please clarify
Please describe why you wish to be a Mentor or Volunteer for children of abuse?
MEDICAL CONCERNS
Do you have any medical conditions or concerns, driving issues or concerns, or are you taking any medications that you believe could prevent you from being an effective volunteer that we need to know about in order to help you be effective at The Guide Of Destiny Foundation?

No Yes
Please Describe:
Education
High School Name *
Date of Graduation *
College
College Major
Date of Graduation
Other Education
Personal References* (required for first time volunteers only) No former employers or relatives.

Please notify your references that they will be contacted via email or phone. Your application will not be processed until all references have been checked.
Reference #1 - Name *

First Name Last Name
Reference #1 - Phone *

Area Code Phone Number
Reference #1 - Email *

Confirmation Email
Reference #2 - Name *

First Name Last Name
Reference #2 - Phone *

Area Code Phone Number
Reference #2 - Email *

Confirmation Email
Reference #3 - Name *

First Name Last Name
Reference #3 - Phone *

Area Code Phone Number
Reference #3 - Email *

Confirmation Email
Personal Profile
Please describe any previous experience working with children: *
Please describe any previous experience working with children who have been abused or neglected: *
Do you feel you could lead a 15-minute speaking event with your youth with materials we provide?

No Yes
List five (5) strengths you have in working with children: Please be specific *
List five (5) weaknesses you have in working with children: Please be specific *

Following Rules: How well do you follow rules and respond to authority

	1	2	3	4	5

1 is Very Well, 5 is Poorly

How do you feel you would be best utilized in this organization?
I would prefer my youth to be:

7 years old 8 years old 9 years old 10 years old 11 years old
Criminal Background

If your records have been expunged pursuant to applicable law, you are not required to answer yes to the following questions. If you are unsure whether to answer yes, we strongly suggest that you answer yes and fully disclose all incidents to avoid any future risk of embarrassment upon disclosure.
1) Have you ever been convicted of or pleaded guilty to any crimes (including crimes of record which have been expunged and pleas of 'no contest'), including municipal, state and federal? *

No Yes
2) Have you ever been placed on probation, received a Suspended Execution, Suspended Sentence or Suspended Imposition of Sentence for any offense involving a minor child (a child under 18), or been placed on ANY local, state, or federal sexual registry? *

No Yes
3) Have you ever been sued in a civil court of law where the allegations in the suit involved illegal, inappropriate, or sexual conduct or contact with a minor child? *

No Yes
4) Have you ever been subject to any court order involving any sexual, physical or verbal abuse including but not limited to any domestic violence or civil harassment injunction or protective order? *

No Yes
5) Have you ever resigned, been terminated or been asked to resign from a position, whether paid or as a volunteer, due to a complaint(s) of sexual, physical or verbal abuse of minors? *

No Yes
If yes to any above, please explain: *
Print Name *
Signature *
Thank you for your interest in being a part of The Guide Of Destiny Foundation Team!
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

MENTOR/ STAFF APPLICATION

MEDICAL CONCERNS

Education

Personal References* (required for first time volunteers only) No former employers or relatives.

Personal Profile

Criminal Background

Thank you for your interest in being a part of The Guide Of Destiny Foundation Team!