Mentor Application |

Mentor Information - Step 1 of 13

Identifying Information *

First

Middle

Last

Gender *

Male
Female

Date of Birth *

Preferred School / Location *

Employer *

Employment Start Date *

Are You A Take Stock In Children Graduate? *

Ethnic Group (check one) *

Caucasian
African American
Third Choice
Hispanic
Asian
Other

If Other Please Specify

Age Category *

18-30
31-40
41-50
51-60
61+

Are You Married? *

Do You Have Children? *

Number Of Sons & Their Ages

Number Of Daughters & Their Ages

Second Languages Spoken

When you were a teenager, to what income group did your family belong? *

Low Income
Middle Income
High Income

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone *

Cell Phone *

Email *

Highest Education Completed (check all that apply) *

Some School, Not a high school graduate
GED
High School Graduate

Associates Degree

Associates Degree

Associates Degree In & Name Of School

Technical / Vocational Certificate

Technical / Vocational Certificate

Technical / Vocational Certificate In & Name Of School

Bachelor's Degree

Bachelor's Degree

Bachelor's Degree In & Name Of School

Master's Degree

Master's Degree

Masters Degree In & Name Of School

Other

Other

If Other Specify

Are you currently enrolled in any education or training program? *

If Yes, Please Specify

How Would You Describe Your Communication Style? (choose one) *

Friendly & Outgoing
Usually wait to be approached by someone new
Reserved until I get to know someone new

I Am Interested In Becoming A Mentor Because (check all that apply) *

I think I’d be a positive role model
I like children
I have the time to give
I overcame difﬁculties growing up and would like to help someone else
I think I have the personality and abilities to be a good mentor
I am interested in making a difference in the life of a child
I believe in the value of mentoring
I wish I had had a mentor when I was a teenager

Do you have any speciﬁc training or experience in dealing with any of the following youth issues: (check all that apply, and if yes, please explain)

Drug Awareness

Drug Awareness

Teen Pregnancy *

Teen Pregnancy

Teen Pregnancy

Teen Violence *

Teen Violence

Teen Violence

Sex / Abstinence *

Sex / Abstinence

Sex / Abstinence

Other *

Other

Other

List Any Clubs Organizations Of Which You Are Currently A Member? *

Are There Any Particular Problems You Would Prefer Not To Handle As A Mentor? *

Which Of The Following Activities Do You Enjoy Participating In Or Watching? (Check all that apply)

Sports

Sports

Handicrafts

Handicrafts

Sports (copy)

Activities

Outdoor Life
Mechanics / Science
Literature
Pop Culture (Movies, TV, etc)
Collecting
Other

Sports (copy) (copy)

Is there anything else you would like us to know about you? If yes, please explain

The undersigned acknowledges and agrees that 1) he or she is not obligated, if called upon, to perform the volunteer services herein applied for; 2) Take Stock in Children is not obligated to assign or actively seek to assign her or him a Take Stock in Children student; 3) as part of the Take Stock in Children matching process, additional information may be requested from the applicant, and 4) Take Stock in Children reserves the right at all times to terminate any match between any volunteer mentor and student for whatever cause. I declare that all of the statements made in this application are true, complete and correct to the best of my knowledge. *

Date *

As a mentor in the Take Stock in Children program, I will always act in a behavior that is in the best interest of my student. Accordingly, I pledge to each of the following volunteer policy statements. Please initial your approval next to each statement. *

I will adhere to all volunteer policies of my local school district.
I will notify Take Stock in Children if I must terminate my mentor position for any reason.
I will notify my student or his or her school liaison or the Take Stock in Children Student Advocate if I am unable to attend a previously scheduled meeting.
I will not willfully arrange contact with my student off school property and not under the supervision of Take Stock in Children or school ofﬁcials.
I will not drive my student in my car.
I understand that Take Stock in Children will terminate my relationship with my student if I violate any of the above policies

Please print COMPLETE name, address, and relationship of three people. They must have known you for at least 2 years. Each should be in a position to evaluate your qualiﬁcations as a mentor. Please do not include family members, current boyfriends, girlfriends, or ﬁancées as references. *

Address *

Zip Code *

Phone *

Relationship *

Years Known *

Reference Two

Reference Name Two

Address

Zip Code

Phone Number

Relationship

Years Known

Reference Three

Reference Name Three

Address

Zip Code

Phone Number

Relationship

Years Known

Work Reference: If you are currently employed, please print the name and address of your work supervisor.  If employed less than 6 months, the previous employer. *

Address *

Zip Code *

Phone Number *

Relationship *

Years Known *

I do hereby afﬁrm the above information is true. I understand if denied acceptance into a mentoring program, no reason for denial will be given. I hereby consent to *

to release information to other entities, agencies, or individuals. I hereby release Take Stock in Children from any liability whatsoever for any information released or any acts or omissions connected with this application. I understand and consent to Take Stock in Children examining any and all available records or information from any source, to include but not be limited to criminal records. I hereby allow Take Stock in Children to release any information compiled from my interview, references, or other sources pertaining to my application to become a mentor to Take Stock in Children. Take Stock in Children will use this information for the purpose of evaluating my ability to meet the initial criteria to serve as a mentor with a mentoring agency. I hereby release  Take Stock in Children from any liability, debt, claim, suit, or obligation of any nature whatsoever should any information be obtained by any other individual, party, or entity of any nature whatsoever. *

Date *

Print Name *

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