Mentor ApplicationMentor Information - Step 1 of 13Identifying Information *FirstMiddleLastGender *MaleFemaleDate of Birth *Preferred School / Location *Employer *Employment Start Date *Are You A Take Stock In Children Graduate? *YesNoNextEthnic Group (check one) *CaucasianAfrican American Third ChoiceHispanicAsianOtherIf Other Please SpecifyAge Category *18-3031-4041-5051-6061+Are You Married? *YesNoDo You Have Children? *YesNoNumber Of Sons & Their AgesNumber Of Daughters & Their AgesSecond Languages SpokenWhen you were a teenager, to what income group did your family belong? *Low IncomeMiddle IncomeHigh IncomePreviousNextHome Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Work Phone *Cell Phone *Email *PreviousNextHighest Education Completed (check all that apply) *Some School, Not a high school graduateGEDHigh School GraduateAssociates DegreeAssociates DegreeAssociates Degree In & Name Of SchoolTechnical / Vocational CertificateTechnical / Vocational CertificateTechnical / Vocational Certificate In & Name Of SchoolBachelor's DegreeBachelor's DegreeBachelor's Degree In & Name Of SchoolMaster's DegreeMaster's DegreeMasters Degree In & Name Of SchoolOtherOtherIf Other SpecifyAre you currently enrolled in any education or training program? *YesNoIf Yes, Please SpecifyPreviousNextHow Would You Describe Your Communication Style? (choose one) *Friendly & OutgoingUsually wait to be approached by someone newReserved until I get to know someone newI Am Interested In Becoming A Mentor Because (check all that apply) *I think I’d be a positive role modelI like childrenI have the time to giveI overcame difficulties growing up and would like to help someone elseI think I have the personality and abilities to be a good mentorI am interested in making a difference in the life of a childI believe in the value of mentoringI wish I had had a mentor when I was a teenagerPreviousNextDo 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 AwarenessDrug AwarenessTeen Pregnancy *Teen PregnancyTeen PregnancyTeen Violence *Teen ViolenceTeen ViolenceSex / Abstinence *Sex / AbstinenceSex / AbstinenceOther *OtherOtherPreviousNextList Any Clubs Organizations Of Which You Are Currently A Member? *Are There Any Particular Problems You Would Prefer Not To Handle As A Mentor? *PreviousNextWhich Of The Following Activities Do You Enjoy Participating In Or Watching? (Check all that apply) SportsSportsHandicraftsHandicraftsSports (copy)ActivitiesOutdoor LifeMechanics / ScienceLiteraturePop Culture (Movies, TV, etc)CollectingOtherSports (copy) (copy)Is there anything else you would like us to know about you? If yes, please explainPreviousNextThe 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 *PreviousNextAs 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 policiesPreviousNextPlease 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 TwoReference Name TwoAddressZip CodePhone NumberRelationshipYears KnownReference ThreeReference Name ThreeAddressZip CodePhone NumberRelationshipYears KnownPreviousNextWork 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 *PreviousNextI 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 *PhoneSubmit