Become A Mentor! | I Am Whole Mentori 1

First name

Last name

Gender

Female

Address

Phone

Email

Employer Name, Address & Phone

Occupation

Please state your Religion/Belief

VOLUNTEER INFORMATION:

Indicate your age preference of mentee (select one):

What do you feel are the strengths (multi-language, math skills, previous relevant volunteer experience, etc.) you can bring to this program?

Write a brief statement on why you have chosen to participate in the mentor program.

Initial the two statements below:

I understand that the mentor program involves spending a minimum of two face-to-face monthly meetings for one year with an assigned mentee.

I understand that I will be required to complete the mentor program orientation and at least two training sessions during the year.

Within the past 5 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance?

Yes

No

Are you under current indictment or have a district/county attorney accepted an official complaint for any of the offenses in question #5?

Yes

No

If the answer is YES to questions 5 or 6, please explain below:

What is the best time for you to volunteer? (check all that apply):

Mornings

Afternoons

Evenings

Weekends

Please list four references (please include at least one family member, one friend and one work reference):

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

In making this application to be a volunteer, I understand that I Am Whole routinely performs criminal and driving record checks of all volunteers for the position of mentor for which I am applying. This check may be done on me if I sign below. If I fail to sign, it may be grounds for rejecting me as a mentor.

I certify to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and on subsequent mentor application

forms, is grounds for dismissal.

Signature

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Date

Month

Day

Year

Adapted from materials provided by Mentoring Partnership of Long Island, The ABC’s of Mentoring, and California Governor’s Mentoring Partnership.

Optional Information:

Social Security number (needed for criminal record checks):

Birth date (needed for record checks):

Month

Day

Year

Do you prefer working with:

A quiet, reserved mentee

Outgoing Mentee

No preference

Do you prefer working with a mentee from a specific racial/ethnic group?

Yes

No

No preference

Specify Race/Group

Do you speak a foreign language?

Please list any hobbies or interests you may have:

What would you like to do with a mentee?

What clubs or groups, if any, do you belong to?

What is your least favorite school subject?

What is your most favorite school subject?

What qualities would you like in a mentee?