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Mentor Application
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Mentors
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Who We Are
About Us
Partners
Success Stories
Get Involved
Mentor Application
Student Application
Donate
Contact
Students
Mentors
Donate
Who We Are
About Us
Partners
Success Stories
Get Involved
Mentor Application Form (Page)
Mentor Application
Student Application
Contact
Students
Mentors
Mentor Application
Fill out the form below or
Download the 2023-2024 Mentor Application
Mentor Information
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Step
1
of 10
Identifying Information
*
First
Middle
Last
Salutation
Date of Birth
*
Social Security Number
*
Driver's License #
Gender
*
Male
Female
Preferred School / Location
*
Employer
*
Title
*
Employment Start Date
Are You A Take Stock In Children Graduate?
*
Yes
No
I heard about the TSIC program and want to become involved:
Yes
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 a mentor when I was a teenager
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?
Is there someone in particular you would like to be matched with?
Next
Ethnic Group (check one)
*
Caucasian
African American
Third Choice
Hispanic
Asian
American Indian/Native American
Other
If Other Please Specify
Age Category
*
18-30
31-40
41-50
51-60
61+
Are You Married?
*
Yes
No
Do You Have Children?
*
Yes
No
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
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Next
Home Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
*
Work Phone
Cell Phone
Email
*
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Next
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
Master's Degree (copy)
Doctorate
Doctorate In & Name Of School
Other
Other
If Other Specify
Are you currently enrolled in any education or training program?
*
Yes
No
If Yes, Please Specify
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Next
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
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Next
Which Of The Following Activities Do You Enjoy Participating In Or Watching? (Check all that apply)
Sports
Sports
Handicrafts
Handicrafts
Sports (copy)
Which of the following activities do you enjoy participating in or watching? (Check all that apply)
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
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Next
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
*
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Next
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
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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
*
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Next
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
*
How did you hear about us?
Phone
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