Mentor Application |

Which area of town would be most convenient for you to serve as a mentor:

(check all that apply)

North
South
Downtown (Urban core)
West
Beaches

Identifying Information

Name*

First Last

Gender*

Male
Female

Date of Birth

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Work Phone

Mobile Phone

Fax

Email*

Place of Employment*

Title*

Employment Address

Street Address Address Line 2 City State ZIP Code

Employment Start Date*

Background Information

Ethnic Group*

Age Category*

Are you married?

Yes
No

Do you have children?*

Yes
No

Children

Son or Daughter	Age

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

Low income
Middle income
High income

Career/Education Information

Highest education completed*

Degree/Certificate Details

Subject/Speciality?	What School/Institution?

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

Yes
No

Please specify

Mentor Information

Have you been through Mentor Training?*

Yes
No

How would you describe your communication style?*

Friendly and 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 a long-term relationship with 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)

Drug awareness
Teen pregnancy
Teen violence
Sex/abstinence
Other

Please explain your training experience

Please indicate how comfortable you would be in talking to a student about the following:

World of work*

Goal setting*

Career Planning*

College Planning*

Personal Experiences*

Hobbies / Interests*

Personal Problems*

Drug Awareness*

Sex / Abstinence*

Please indicate how comfortable you would be in handling the following potential problems

You have a hard time reaching your student.*

You make arrangements to meet and your student doesn’t show.*

Your student seems unresponsive to your interest in getting to know him/her.*

Your student calls you too often.*

Your student asks you for money.*

Your student has little interest in your job/profession.*

Your student shares very sensitive thoughts or information with you.*

Are there any particular problems you would prefer not to handle as a mentor?

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

References

Please complete the name, address, and the relationship of two 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.

Reference 1*

Name Address Zip Phone

Phone

Relationship to you*

Number of years known*

Reference 2*

Name Address City State ZIP Code

Phone

Relationship to you*

Number of years known*

If you are currently employed, please print the name and contact information of your work supervisor. If employed less than 6 months, the previous employer.*

Name	Title	Phone & Ext.	Email

Take Stock in Children Mentor Interest Form

Place a check mark next to any activity you enjoy participating in or watching.

Sports*

Please specify what other sports you are interested in

Outdoor Life*

Please specify what other outdoor life you are interested in

Science and Mechanics*

Please specify what other science and mechanics you are interested in

Handicrafts*

Please specify what other handicrafts you are interested in

Collecting*

Please specify what other collecting you are interested in

Indoor Activities*

Please specify what other indoor activities you are interested in

From all the above items, the three I like best are:*

Activity 1	Activity 2	Activity 3

Do you have any pets? What kinds?*

Do you play any musical instruments? Which ones?*

What clubs or organizations do you belong to?*

If you had three wishes, what would you wish for?*

Wish 1	Wish 2	Wish 3

Signature

Phone

This field is for validation purposes and should be left unchanged.