Apply

Become a Mentor

Please complete application below.

Name

Date

Date of Birth

Address

City

State

Zip

Work Phone

Cell Phone

Gender

Occupation

Language(s) Spoken

Employer

Street Address

City

State

Zip

Phone

Supervisor’s Name

Supervisor’s Title

Dates of Employment From

Dates of Employment To

Position Held

1. Why do you want to become a mentor ?

2. Do you have any previous experience volunteering 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. How would your friends, family, and co-workers describe you?

5. Have you ever been arrested or convicted of a crime? If so, what were the circumstances?

6. Do you have a current addiction or dependence to drugs or alcohol?

7. Do you have a medical, substance abuse or mental disorder that would interfere with your ability to be a mentor? Please explain.

8. Have you ever been investigated or convicted of child abuse or neglect, or sexual abuse or molestation? If yes, please explain.

Please read this carefully before signing:
MCIP 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 MCIP 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 the MCIP Mentoring Program to use any photographic images, videos, or recordings 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:
Information Release Form
Personal References Form
Interest Survey Form
DCPS Screening Procedure, including:
(i) A Child Protection Register (CPR) check
(ii) A Sex Offender Registry (SOR) check
(iii) screening for criminal background
(iv) mandatory drug and alcohol testing
(v) TB screening and other health risks
(vi) fingerprinting
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