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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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
Very Well
Poorly
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!
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