Application

Tandem Mentorship Program appreciates your interest in becoming a mentor. Be advised that you will be required to provide copies of your driver's license and auto insurance.  You can choose to scan or photograph and upload these items below where prompted (Document 1, Document 2), or allow us to scan them for you at your mentor interview.

Show me the path where I should walk, O Lord, point out the right road for me to follow." Psalm 25:4

Basic Information
* First Name
Middle Name
* Last Name
Email Address
Contact Information
Home Address 1
Home City
Home State
Home Zip Code
Home Phone
Mobile Phone
Work phone
Preferred Method of Communication
Home PhoneCell Phone
Work PhoneEmail
Basic
* Date of Birth
Marital Status
Spouse First Name
Spouse Last Name
Demographic Information
* Gender
Ethnicity
Other
Other
Disability
Type of Disability
Type of Disability Other
Availability
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
Transportation
Own Car
Drivers License
Drivers License State
Drivers License Number
Mentor Preferences for Match
Willing to be matched with mentee from home with a history of
Education
Education Level
Other
Documents
Document Type 1
Document 1
No file is currently uploaded.
Upload File
Document Type 2
Document 2
No file is currently uploaded.
Upload File
Program Questions
Why do you want to be a mentor?
Please write down your interests and a few activities you would like to do with a mentee
How did you hear about Tandem?
* Please list the names, e-mails, and phone numbers of three people you would like to use as character references (only people you have known for at least a year). Include at least one person who can comment on your current walk with Jesus.
* Proof of Auto Insurance- If you weren't able to upload a photo of your insurance card above in the document upload please provide your auto insurance company name, policy number, and phone number
* Please list all other cities, states, and dates of residency during the past 10 years
* Please list the names and ages of your household members
* Please provide employment information for the past 5 years. Include company name, position held and length/duration of employment.
* How would you describe your relationship with Christ? How would you share your faith-walk with your mentee?
* Do you have any previous experience volunteering or working with youth facing adversity? If so, please specify.
* Have you ever been arrested or convicted of a crime? If so, what were the circumstances?
* Have you ever been convicted of a DUI, driving while under the influence of alcohol? If yes, when and what were the circumstances?
* Have you ever been treated or hospitalized for a mental health disorder? If yes, please explain.
* Have you ever been treated for alcohol or substance abuse? If yes, please explain.
* Have you ever been investigated or convicted of child abuse, neglect, sexual abuse or molestation of a youth 18 or younger? If yes, please explain.
Electronic Signature
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I understand it will be necessary for Tandem Mentorship Program to conduct a background check regarding my driving record, criminal history, and personal references in connection with my application for employment or to serve as a volunteer with Tandem (513free, Inc.), I understand that a "consumer report" and/or "investigative consumer report", as defined by the Fair Credit Reporting Act (15 U.S.C. § 1681), will be requested by Client for employment or volunteer purposes, whichever is applicable, from Protect My Ministry, Inc., ("Protect My Ministry"), a consumer reporting agency as defined by the Fair Credit Reporting Act. Further, I provide permission for Tandem to conduct the same investigation of my background in previous states in which I have resided.

Further, I understand that information about myself will be anonymously (without my name) shared with a prospective mentee(s) and his/her parent(s)/guardian(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and any other information known about me may be shared with the mentee and parent/guardian to ensure and aid in facilitating a safe and successful match relationship.

I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.

I understand that Tandem Mentorship Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.

I authorize that non-identifying information may be gathered about program participants and shared with other participants, individuals, or organization.

I agree to allow Tandem Mentorship Program (513Free, Inc.) to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials. 

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By signing, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.