ࡱ> jlkU@ ?bjbj [{T||||hhhh,,Jj   $Rvs" ss||s|8s @uЍh<0J||||||| 09"[w     Mentor Application Date: _________________ Name: ___________________________________________ Drivers License # _________________________ Home Address: ____________________________________________________ City: ___________________________ State: __________ Zip: ____________ Home Phone: ______________________ Work Phone ________________________ Cell Phone: ________________________ email: ____________________________ Employer: __________________________________________ Title: _________________________________ Length of Employment: ______________Supervisors name: ________________________________________ Have you ever been convicted of a crime? __________If Yes, please explain:___________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ Do you object to our agency running a background check on you? ________________________ Mentoring Information Why do you want to be a mentor? ______________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ Can you meet with a child as often as our program requires?__________________________________________ Do you have any previous experience volunteering or working with youth? _______________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ What times can you meet with your mentee? During lunch: ______ After school: _______ After 5:00: _______ Weekends: _______ During regular business hours: _______ Do you have any hobbies or special skills? ______________________________________________________ ______________________________________________________________________________________________________________________________________ Would you prefer to be matched with a child from a specific: Grade level: _______ Ethnicity: _______ Gender: _______ Would you be willing to work with a child who has disabilities? __________________ Can you speak any other languages? ____________________________________________________________ For training would you prefer to meet: ( Weekdays (a.m. (p.m. ( Weekends (a.m. (p.m. References Please list the names, addresses, and phone numbers of three people you would like to use as character references (please list only people you have known for at least a year): Name: ______________________________________ Address: ______________________________________ City: _________________________________________State: ___________________ Zip: _________________ Phone: _______________________________________Relationship: __________________________________ Name: _______________________________________Address: ______________________________________ City: _________________________________________State: ___________________ Zip: _________________ Phone: _______________________________________Relationship: __________________________________ Name: _______________________________________Address: ______________________________________ City: _________________________________________State: ___________________ Zip: _________________ Phone: _______________________________________Relationship: __________________________________ Please read this carefully before signing: Our program appreciates your interest in becoming a mentor to a child. 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