Mentor Application

Application to Become a Mentor

"*" indicates required fields

Step 1 of 7

Mentor Application

Your Personal Information

Your Name*

First Last

Date*

Today's Date

Address*

Street Address City State ZIP Code

Home Phone*

Work Phone

Cell Phone

Best Contact Number*

May We Text You?*

May We Contact You During Business Hours?*

If Not, When are the Best Times to Call You?

Your Email Address*

Enter Email Confirm Email

Date of Birth*

Gender

Male

Female

Race

Ethnicity

Marital Status

Primary Language*

Other Languages Spoken

Please List all Members (INCLUDING PETS) of Your Household

Name

Sex

Age

Relationship to Applicant

Please 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*

Employment

Employment Status*

Full Time

Part Time

Not Employed

Retired

Please Provide Your Most Current Employment Information

Employer:

Street Address

Street Address City State ZIP Code

Telephone Number

Dates of Employment

Start

Dates of Employment

End

Position 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 Institution

Graduation Date (or Anticipated)

Major or Area of Study

College:

Name of Educational Institution

Graduation Date (or Anticipated)

Major or Area of Study

Other (Graduate Program or Vocational School):

Name of Educational Institution

Graduation Date (or Anticipated)

Major or Area of Study

Application Questions

Please 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.

5. 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

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

19. Are you willing to attend mentor orientation and training sessions prior to and after being matched?*

Yes

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

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*

SETON YOUTH SHELTERS MCP PROGRAM

Changing Lives, Building Futures

Personal References

Please 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 Number

Relationship

How Long Known?

Name

First Last

Phone Number

Relationship

How Long Known?

Name

First Last

Phone Number

Relationship

How Long Known?

Name

First Last

Phone Number

Relationship

How Long Known?

Name

First Last

Phone Number

Relationship

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*