Mentor Application Personal InformationName: Date MM slash DD slash YYYY Street Address: State: Zip: City: Home phone:Work phone:Date of Birth MM slash DD slash YYYY Gender Male Female Employment HistoryPlease provide employment information for the past five years, with the most recent position held first. If more space is needed use an extra sheet of paper. Employer: Street Address: City: State: Zip: Supervisor’s Name: Title: Phone:Dates of Employment: MM slash DD slash YYYY to MM slash DD slash YYYY (m/year)Position Held:Please provide employment information for the past five years, with the most recent position held first. If more space is needed use an extra sheet of paper. Employer: Street Address: City: State: Zip: Supervisor’s Name: Title: Phone:Dates of Employment: MM slash DD slash YYYY to MM slash DD slash YYYY (m/year)Position Held:Please provide employment information for the past five years, with the most recent position held first. If more space is needed use an extra sheet of paper. Employer: Street Address: City: State: Zip: Supervisor’s Name: Title: Phone:Dates of Employment: MM slash DD slash YYYY to MM slash DD slash YYYY (m/year)Position Held:Application QuestionsPlease 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. Why do you want to become a mentor? Do you have any previous experience volunteering or working with youth? If so, please specify. What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain. Can you commit to participating in the NMI for a minimum of one year from the time you are matched with a youth? Are you available to mentor at least four hours per month? Please explain any particular scheduling issues. How would you describe yourself as a person? How would your friends, family, and co-workers describe you? Have you ever been arrested or convicted of a crime? If so, what were the circumstances? Have you ever used illegal drugs? If so, what substances were used and how often? Are you currently using any illegal drugs or controlled substances? Have you ever received treatment for alcohol or substance abuse? If yes, please explain. Have you ever been treated or hospitalized for a mental disorder? If yes, please explain. Have you ever been investigated or convicted of child abuse or neglect? If yes, please explain. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? If yes, please explain. 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? 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:NMI 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 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 NMI is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor. I understand that NMI is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.(optional) I agree to allow NMI 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. (optional) I agree to allow NMI 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. 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 SignatureDate MM slash DD slash YYYY
