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 Phone Cell Phone
Work Phone Email
Motivational Factors
Motivational Factors Other
Demographic Information
* Gender
Primary Language
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
Career Focused Interests
Career Focused Interests Comments
Mentor Preferences for Match
Age Range
School Name
Education Level
Recruitment Source
Program Questions
* Are you 18 years of age or older?
Have you previously applied to volunteer with LSI?
Church Affiliation
* Why are you interested in becoming a Social Capital Coach?
Have you had previous experience in mentoring?
If so, please describe:
If you wish, please share any other information or comments in regard to your application for this position.
Do you have any special needs which would assist or hinder your ability to mentor?
* Social Capital Coaches are required to commit to once a week visits for a minimum of one hour over a period of six to nine months. Do you foresee any challenges to maintaining this commitment? If so, please describe.
Reference 1 Name
Primary Phone Number
Email Address
Reference 2 Name
Primary Phone Number
Email Address
Reference 3 Name
Primary Phone Number
Email Address
* Have you ever been convicted of dependent adult/child abuse, neglect, or sexual abuse?
* Have you ever been convicted of any offense against the law, including deferred judgments, or forfeited collateral?
* I understand I will need to complete authorization forms for Lutheran Services in Iowa to run background checks.
* I understand my social security number will be used for the sole purpose of running background checks.
* If transportation is a function of my position, I give my permission to have Lutheran Services in Iowa run a motor vehicle report.
* I acknowledge that consideration of my volunteer application is contingent upon the results of reference checks, background checks, and an interview.
* By typing my full name here I authorize Lutheran Services in Iowa to accept an electronic signature on this application.