MENTOR APPLICATION

Personal Information:
First Name*
Last Name*
Gender* Male    Female   
Address
City
State
Zip
Home phone
Mobile phone
Name/address of employer
Work phone
Occupation
E-mail address*

Volunteer Information:
Indicate your age preference: Ages 18-25   
Ages 26-35   
Age 36-45   
Age 46-55   
Age 56-65   
Age 65-On Up   
What do you feel are the strengths (bilingual, skills, education, previous relevant volunteer or work experience, etc.) you can bring to this program?
Write a brief statement on why you have chosen to participate in the mentor program.

Initial the two statements below:
I understand that the mentor program involves spending a minimum of one hour every week for one full year for the mentor & mentee to reap the full benefits of this relationship.   
I understand that I will be required to complete the mentor program orientation, Christ Esteem Workshop and at least one training sessions during the year.   

Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance? Yes    No   

Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in question #5? Yes    No   
If the answer is YES to questions 5 or 6, please explain below:
Educational Background (mark one): Some high school   
Graduate/professional school   
High school graduate   
Technical school   
College graduate   
Some college   
Other   
Why do you want to become a mentor?
What days of the week are you available to volunteer? (check all that apply): Monday   
Tuesday   
Wednesday   
Thursday  
 Friday   
Saturday   
Sunday   
What is the best time for you to volunteer? (check all that apply): Mornings   
Afternoons   
Evenings   
Weekends   

Please list four references (please include at least one family member, one personal friend and one work reference):
Name
Address
City
State/ZIP
Phone number
Relationship
Name
Address
City
State/ZIP
Phone number
Relationship
Name
Address
City
State/ZIP
Phone number
Relationship
Name
Address
City
State/ZIP
Phone number
Relationship

In making this application to be a volunteer, I understand that the Women in Transition to Glory Services, Inc. routinely performs criminal and driving record checks of all volunteers for the position of mentor for which I am applying. This check may be done on me if I sign below. If I fail to sign, it may be grounds for rejecting me as a mentor.

I certify to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and on subsequent mentor application forms, is grounds for dismissal.

Signature*
Date*

Adapted from materials provided by Mentoring Partnership of Long Island, The ABC’s of Mentoring, and California Governor’s Mentoring Partnership.
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