Mentor Application
Applicant Name
*
First Name
*
Middle Name
*
Last Name
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Occupation
*
Employer
*
Emergency Contact
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email Address
*
Relationship To You
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Information
Will this be your first time participating in a mentoring program?
*
Yes
No
If no, in what capacities have you served as a mentor or had a mentor yourself, and what was your experience like?
Rank your attributes - the top item is the attribute that you feel is your strongest.
*
Why do you believe you would be a strong mentor?
*
Please provide any other information you believe would be important in review of this application.
Please list special skills, educational background, other languages, ect.
Do you consent to a drug screening?
*
Yes
No
Do you consent to a background check?
*
Yes
No
Do you have experience working with troubled youth?
*
Yes
No
If yes, please explain.
Do you have any physical limitations that may prevent you from performing the volunteer position for which you are applying for?
*
Yes
No
If yes, please explain.
Do you have a clean driving record (transportation of mentees may be needed)?
*
Yes
No
If no, please explain.
Do consent to auto insurance verification?
*
Yes
No
If no, please explain.
Applicant Availability
Please select the days you are available to meet with mentees & for meetings? * Event availability will be determined separately*
Yes
NO
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Heading
On the days that YOU ARE available, please list the window of time you are available (ex. from 10am-1pm & 4pm-9pm) .
Time(s) Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Is there any area of volunteer work that you would not wish to be asked to serve?
*
Yes
No
If yes, please describe.
References
Please list the names, email addresses, and phone numbers of 3 people you would like to use as character references (only people you have known for at least 1 year). Include only 1 relative. Any information Girl Talk Today gathers from these references will be held as confidential and not released to the applicant.
Reference #1
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Relationship To You
*
Reference #2
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Relationship To You
*
Reference #3
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Relationship To You
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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