Mentor Application Application to Become a Mentor "*" indicates required fields Step 1 of 7 14% Mentor ApplicationYour Personal InformationYour Name* First Last Date*Today's DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Work PhoneCell PhoneBest Contact Number*May We Text You?*YesNoMay We Contact You During Business Hours?*YesNoIf Not, When are the Best Times to Call You? Your Email Address* Enter Email Confirm Email Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Male Female Race Ethnicity Marital Status Primary Language* Other Languages Spoken Please List all Members (INCLUDING PETS) of Your HouseholdNameSexAgeRelationship to Applicant Add RemovePlease List an Alternate Contact to Reach You, Only if We are Unable to Reach You With the Telephone Number Listed Above (Friend, Family Member):Name* First Last Relationship* Phone* EmploymentEmployment Status* Full Time Part Time Not Employed Retired Please Provide Your Most Current Employment InformationEmployer: Street Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Telephone NumberDates of EmploymentStartMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Dates of EmploymentEndMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Position Held Supervisor's Name First Last Supervisor's Title *If you or your partner are military affiliated, when are you expected to receive your next orders? Please Provide Your Education Information:High School or GED:Name of Educational InstitutionGraduation Date (or Anticipated)Major or Area of StudyCollege:Name of Educational InstitutionGraduation Date (or Anticipated)Major or Area of StudyOther (Graduate Program or Vocational School):Name of Educational InstitutionGraduation Date (or Anticipated)Major or Area of Study Application QuestionsPlease answer all of the following questions as completely as possible.1. What interests you about becoming a mentor?*2. Have you ever applied to be a mentor before? If yes, when and where?*3. Do you have any previous experience volunteering or working with youth? If so, please specify.*4. Please list any certifications, trainings, or other experiences directly related to children that you may have. Add Remove5. What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain.*6. Can you commit to participate in the Seton Youth Shelters MCP Program for a minimum of one year from the time you are matched with a youth?*This includes meeting with a mentee at least two times per month for at least four hours per month. Yes No 7. Describe your general health.*8. How would you describe yourself as a person?*9. How would your friends, family, and co-workers describe you?*10. Have you ever been arrested or convicted of a crime? If so, what were the circumstances?*11. Please describe your DMV record.*12. Have you ever used illegal drugs? If so, what substances were used and how often?*13. Have you ever been convicted of a DUI, drinking while under the influence of alcohol or other drugs or narcotics? If yes, when and what were the circumstances?*14. Have you ever received treatment for alcohol or substance abuse? If yes, please explain.*15. Have you ever been treated or hospitalized for a mental health issue? If yes, please explain.*16. Have you ever been investigated or convicted of child abuse or neglect? If yes, please explain.*17. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? If yes, please explain.*18. Are you willing to communicate regularly and openly with program staff, provide monthly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program?* Yes No 19. Are you willing to attend mentor orientation and training sessions prior to and after being matched?* Yes No Please read this carefully before signing:Seton Youth Shelters MCP Program appreciates your interest in becoming a mentor. Please check each of the following:I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.* Yes I understand that Seton Youth Shelters MCP Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.* Yes (optional) I agree to allow Seton Youth Shelters MCP Program to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials. Yes No I understand I must agree to provide the following information during the pre-match training (after an interview is completed), and that any incomplete information will result in the delay of my application being processed. I also understand that the application process is not complete until I attend the pre-match training, and I agree to cooperate with providing the information necessary for the following forms:* Yes *Note: Seton Youth Shelters will provide all of the release forms after the interview Copy of your valid driver's license and proof of auto insurance Information Release Form Personal References Form Interest Survey Form DMV Release Form (state agency f01m) Criminal History Release Form)(nationwide search) Child Abuse and Neglect Release Form (state agency f01m) NationaI Sexual Offender Registry search By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 SETON YOUTH SHELTERS MCP PROGRAM Changing Lives, Building FuturesPersonal ReferencesPlease list the names and phone numbers of five people you would like to use as character references (only people you have known for at least ONE YEAR). You may use friends, coworkers, and professional contacts, but please limit your references to no more than one family member.Name First Last Phone NumberRelationship How Long Known? Name First Last Phone NumberRelationship How Long Known? Name First Last Phone NumberRelationship How Long Known? Name First Last Phone NumberRelationship How Long Known? Name First Last Phone NumberRelationship How Long Known? I agree to allow Seton Youth Shelters staff to make contact with the above mentioned people to be used as character references for my application to become a mentor through the Mentoring Children of Prisoners Program. I understand that any information Seton Youth Shelters MCP Program gathers from these references will be held as confidential and not released to me, the applicant.Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 SETON YOUTH SHELTERS MCP PROGRAM Changing Lives, Building FuturesMentor Interest SurveyPlease complete all the following. This survey will help Seton Youth Shelters MCP Program know more about you and your interests and help us find a good match for you.What Are the Most Convenient Times for You to Meet With Your Mentee?Please check all that apply. Weekdays Evenings Weekends Select AllOther?If other, what are the most convenient times for you? What Ages Between 4 and 18 Year Olds Are You Most Comfortable Working With? Race Preference, if Any: Are You Comfortable Working With Youth With Special Needs? Yes No Please List all Special Needs You Feel Comfortable Working With.Please List any Type of Special Need, Disability, or Type of Abuse You Would Prefer NOT to Work With:What is One Goal You Have Set for the Future?What Person Do You Most Admire and Why?Describe an Ideal Day Off for You.Is There Anything Else You Feel We Should Know About You? Please Mark All the Activities You Are Interested in:Playing FootballPlaying BasketballPlaying Baseball/SoftballPlaying HockeyPlaying SoccerIce SkatingPlaying VolleyballGoing to the Gym/ExercisingGoing SwimmingWatching BasketballWatching FootballWatching Baseball/SoftballWatching HockeyWatching SoccerWatching Ice SkatingWatching VolleyballWatching GymnasticsWatching Track & FieldFishingHikingGoing to the ParkBike RidingWalkingBeachKayak/CanoeRoller SkatingSkateboardingCookingLibraryBoard GamesMoviesShoppingYogaSingingListening to MusicVideo GamesArts & CraftsTennisDancingGardeningAnimalsDrawingWritingSewingReadingPlease List Any Other Hobbies or Areas of Strong Interest:Favorite Singer: Favorite TV Show: Favorite School Subject: Least Favorite School Subject: I Like to Read Books About: My Favorite Sports Teams Are: Would You Be Interested in Helping a Youth With School Work if That is Something They Could Benefit From? Yes No Please Share Any Religious Affiliation IF You Would to Incorporate Any Religiously Affiliated Activities Into the Mentoring Relationship***Please note Seton Youth Shelters is NOT religiously affiliated and this is not a requirement or a recommendation by Seton Youth Shelters' staff. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.