Thank you for your interest in participating in Healthy Visions' mentoring program!!  Our program is created to encourage the social emotional development of our adolescent youth through a meaningful mentoring relationship between adult volunteers and students. To participate you need to go through a screening process. 


Please take the time to answer the brief list of questions below.  All of the information you provide will be kept confidential.  After your application has been approved you will receive an email to make your mentor profile which will be used to match you with a mentee. After a rountine background check, you will then participate in our first orientation training on September 23rd, 9am-12pm. 


If you have any questions please contact Megan at

Basic Information
* First Name
Middle Name
* Last Name
Email Address
Confirm Password
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
Social Media
* Date of Birth
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Marital Status
Demographic Information
* Gender
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
School Name
Education Level
Year Degree Attained
Program Questions
What do you do for your current employer? (Briefly explain your current job responsibilities)
Current Job Title
Company Name
Work Address
Social Security #
Why do you want to take part in this program?
Have you ever worked with youth? If yes, please explain in what capacity you have worked with you. (What was your role and was it through volunteer activities, your own children, etc?)
* Please list all residences for the past five years, starting with the most recent.
* References: Please list 3 people who know you well and can attest to your character, skill and dependability. Please include their full name, phone number, and relationship to you.
Electronic Signature
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***If on a mobile device use your finger to sign for your signuature, If on a desktop/laptop computer, place cursor in signature box, hold down the left mouse button, and sign the signature box.***


I want to serve as a mentor for Healthy Visions' mentor program. I understand that a third-party investigative agency will be conducting a background check on all volunteer applicants prior to their acceptance into the program. Any information obtained by the investigative agency conducting the background check will be used only in connection with the applicant's participation in Healthy Visions' mentoring program.

By my signature above, I authorize Hamilton County Justice or Dept. of Motor Vehicle Registration to conduct the background check for Healthy Visions' mentoring program and to make investigations and inquiries as necessary for purposes of my participation in this program. I also authorize all law enforcement agencies and courts to release information, if any, concerning me to Hamilton County Justice or   DMV This authorization does not include the release of any medical information. If accepted as a volunteer for Healthy Visions' mentoring program I agree to adhere to the Safety and Program Guidelines outlined in connection with Healthy Visions' mentor program