Thank you for your interest in mentoring! Please complete the Mentoring Village Mentor Application.

Basic Information
* First Name
Middle Name
* Last Name
Email Address
Confirm Password
Contact Information
Home Address 1
Home Address 2
Home City
Home State
Home Zip Code
Home Country
Home Phone
Mobile Phone
Work phone
Work phone ext.
Preferred Method of Communication
Home Phone Cell Phone
Work Phone Email
* Date of Birth
Motivational Factors
Motivational Factors Other
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
Drivers License
Public Transit Available
Career Focused Interests
Career Focused Interests Comments
Mentor Preferences for Match
Age Range
School Name
Education Level
Year Degree Attained
Date Expressed Interest
Recruitment Source
Document Type 1 Other
Document Type 2 Other
Program Questions
* Have you ever worked with youth? If so, please explain in what capacity you have worked with youth
* Reference 1: Please provide the name, phone number, relationship, and best time to call.
* Reference 2: Please provide the name, phone number, relationship, and best time to call.
* Reference 3: Please provide the name, phone number, relationship, and best time to call.
* Please provide the name, relationship, and phone number for your emergency contact.
Electronic Signature
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I want to serve as a mentor for Mentoring Village (MV). 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 MV.

By my signature below, I authorize Verified Volunteers to conduct the background check for Mentoring Village and to make investigations and inquiries as ncessary 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 Verified Volunteers. This authorization does not include the release of any medical information. If accepted as  volunteer for Mentoring Village, I agree to adhere to the Program Guidelines outlined in connection with Mentoring Village.