Mentor Application

Personal Information:
First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Business Phone:
May we contact you at work?
Fax:
E-mail:
Marital Status:
How did you hear about the mentoring program?
Employment:
Are you currently employed?
What is your occupation?
Education:
Education:
If applicable, what Yeshivot did you attend?
Please list any groups or organizations you have participated in (including any camps you have worked in):
Interests:
List any hobbies or special interests that would assist you in mentoring:
Have you ever participated in any mentoring program before?
If yes, what program did you participate in?
Who would you like to mentor?
Personal Statement:
Briefly describe yourself and your motivation for wanting to be a mentor:
Are you confident that you can make a commitment at least 1 hour a week, for one year, with a child / teen on a regular scheduled basis?
Will you be able to meet the following requirements for training and supervision?
1. Two 2 hour mentor training sessions
2. Two additional in-service & supervision sessions yearly
3. Monthly phone contact with a supervisor
4. Keeping a brief log of your contacts with the child or teen
References:
Please list the names and addresses of three people who can serve as character references. You must include a Rav as one reference. You may not include relatives or significant others.
Reference #1:
Name:
Address:
City:
State:
Zip:
Phone:
Reference #2:
Name:
Address:
City:
State:
Zip:
Phone:
Reference #3:
Name:
Address:
City:
State:
Zip:
Phone:
Should be Empty:

Personal Information:

Employment:

Education:

Interests:

Personal Statement:

References: