Basic Information
* First Name
* Last Name
Email Address
Contact Information
Home Address 1
Home Address 2
Home City
Home State
Home Zip Code
Home Phone
Mobile Phone
Preferred Method of Communication
Home PhoneCell Phone
Work PhoneEmail
* Date of Birth
Marital Status
Spouse First Name
Spouse Last Name
Military Service
Owns a Firearm
Tobacco, Alcohol, and Drug Use Histroy
Motivational Factors
Motivational Factors Other
Demographic Information
* Gender
Primary Language
Secondary Language
Secondary Language Other
Type of Disability
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
Own Car
Drivers License
Drivers License State
Drivers License Issue Date
Drivers License Expiration
Career Focused Interests
Career Focused Interests Comments
Mentor Preferences for Match
Age Range
Willing to be matched with mentee from home with a history of
School Name
Education Level
Date Expressed Interest
Recruitment Source
Target Audience
Program Questions
* Name and Contact Phone Number and Address for Mentor Emergency Contact
* Would you ever keep a secret for a mentee from the youth mentoring program staff?
* Do you have lingering concerns or comments about the volunteer mentor position you'd like to discuss with program staff in the mentor interview?
* Children's Friend and Family Services will run a full CORI/SORI background check on every applicant volunteer youth mentor. Is there anything the program staff may expect to see in the report of these checks?
* Please list four individuals we may contact for references. Note: references will not be contacted until after mentor interview and criinal/driving database record checks are completed. Applicant will be informed before reference calls are to be made.