Basic Information
* First Name
Middle Name
* Last Name
Email Address
Contact Information
Home Phone
Mobile Phone
Work phone
Preferred Method of Communication
Home Phone Cell Phone
Work Phone Email
* Date of Birth
Demographic Information
* Gender
Primary Language
Secondary Language
Secondary Language Other
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
Own Car
Public Transit Available
Public Transit
Document Type 1 Other
Document Type 2 Other
Program Questions
Have you ever filed a mentor application with us before?
* Please list three references. Two completed references are required to complete your application. Please include name, phone number, email address, and their relationship to you.
Do you have any experience as a mentor? If yes, where and when?
Are you currently in an abusive relationship?
Did you receive professional treatment for this abusive relationship at some point following your departure? If yes, where and when?
Have you personally survived domestic violence or intimate partner violence in your lifetime? If yes how long ago did this occur and what form of violence have your survived (emotional, physical, sexual or mental)?
What do you this is the cause of domestic violence? How would you define domestic violence as it means to you?
Have you ever been convicted of a crime? (Conviction will not necessarily disqualify an applicant. Any criminal record that has been erased, expunged, or statutorily eradicated does not need to be reported)
How did you hear about Her VOICE?
Why are you interested in mentoring with Her VOICE?
What personal qualities do you have that would make you a good candidate to mentor with Her VOICE?
* What area of Houston do you live?
* Do you prefer your mentee to live in the same area as you?
* What is your preferred age of your mentee?
* What kind of relationship are you hoping to have with your mentee? (casual, formal, etc.)