Personal Information |
| Name:
|
Date: |
| Street Address: |
|
| Home Phone: |
Work Phone: |
| Social Sec. #: |
|
|
|
Please list all members of your household
|
Employment History
Please provide employment information for the past five years, with most recent position held first. If more space is needed use an extra sheet of paper. |
| Employer: |
|
| Street Address: |
|
| Supervisor's Name: |
Title: |
| Phone:
|
| Dates of Employment:
to
(m/year) |
| Position Held:
|
|
| Employer: |
|
| Street Address: |
|
| Supervisor's Name: |
Title: |
| Phone:
|
| Dates of Employment:
to
(m/year) |
| Position Held:
|
|
| Employer: |
|
| Street Address: |
|
| Supervisor's Name: |
Title: |
| Phone:
|
| Dates of Employment:
to
(m/year) |
| Position Held:
|
Application Questions
Please answer all of the following questions as completely as possible. If more space is needed, use an extra sheet of paper or write on the back of this page. |
1. Why do you want to become a Mentor?
2. Do you have any previous experience Mentoring or working with youth? If so, please specify.
3. What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain.
4. Can you commit to participate in the Youth Mentoring Program for a minimum of one year from the time you are matched with a youth?
5. Are you available to meet with a child eight hours per month and have contact at least once per week? Please explain any particular scheduling issues.
6. Describe your general health. Are you currently under a physician’s care or taking any medications? If so, please explain.
7. How would you describe yourself as a person?
8. How would your friends, family, and co-workers describe you?
9. Have you ever been arrested or convicted of a crime? If so, what were the circumstances?
10. Have you ever used illegal drugs? If so, what substances were used and how often?
11. Are you currently using any illegal drugs or controlled substances?
12. Do you drink alcoholic beverages? If so, what and how often?
13. Have you ever been convicted of a DUI, drinking while under the influence of alcohol? If yes, when and what were the circumstances?
14. Do you use tobacco products? If so, what and how often?
15. Have you ever received treatment for alcohol or substance abuse? If yes, please explain.
16. Have you ever been treated or hospitalized for a mental disorder? If yes, please explain.
17. Have you ever been investigated or convicted of child abuse or neglect? If yes, please explain.
18. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? If yes, please explain.
19. 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?
20. Are you willing to attend an initial Mentor training session and two inservice training sessions per year after being matched?
|
Please read this carefully before signing:
Youth Mentoring Program appreciates your interest in becoming a Mentor.
Please initial 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. |
| I understand that the Youth Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a Mentor. |
| (optional) I agree to allow Youth Mentoring 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. |
I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed:
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions. |
Parent/Guardian Signature |
Date |
|
| Please return or mail this application and the items listed above to Youth Mentoring Program, First Nations Community HealthSource,5608 Zuni Rd SE, Albuquerque, NM 87108. |
