Mentor Application Form

Thank you for your submission.

Personal Information

Name*

Please correct your Name.

Date*

Please correct your Date.

Street Address*

Please correct your Street Address.

City*

Please correct your City.

State*

Please correct your State.

Zip*

Please correct your Zip.

Lived at residence since (month/year)*

Please correct your Lived at residence since (month/year).

Previous residence if less than 7 years

Address

City

State

Zip

Home Phone*

Please correct your Home Phone.

Work Phone

Email*

Please correct your Email.

Date of Birth*

Please correct your Date of Birth.

Gender*

Female

Male

Please correct your Gender.

Current and Valid Driver’s License?*

Yes

Please correct your Current and Valid Driver’s License?

Do you own a vehicle or have reliable transportation?*

Yes

Please correct your Do you own a vehicle or have reliable transportation? .

Do you have valid auto insurance that meets state requirements?*

Yes

Please correct your Do you have valid auto insurance that meets state requirements? .

Please list all members of your household:

Name

Sex

Age

Relationship to Applicant

Name

Sex

Age

Relationship to Applicant

Name

Sex

Age

Relationship to Applicant

If you have additional members in your household, please list them here.

Employment History

Please provide employment information for the past five years, with most recent position held first.

1. Employer*

Please correct your Employer.

Address*

Please correct your Address.

Supervisor’s Name*

Please correct your Supervisor’s Name.

Title*

Please correct your Title.

Phone*

Please correct your Phone.

Position Held*

Please correct your Position Held.

Dates of Employment*

Please correct your Employment From.

Please correct your Employment To.

2. Employer

Address

Supervisor's Name

Title

Phone

Position Held

Dates of Employment*

Please answer all the following questions as completely as possible.

Why do you want to become a mentor?*

Please correct your Why do you want to become a mentor?

Do you have any previous experience volunteering or working with youth? If so, please specify.*

Please correct your Do you have any previous experience volunteering or working with youth? If so, please specify.

Describe your general health.*

Please correct your Describe your general health.

How would you describe yourself as a person?*

Please correct your How would you describe yourself as a person?

How would your friends, family, and co-workers describe you?*

Please correct your 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?*

Please correct your 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?*

Please correct your 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?*

Please correct your Are you currently using any illegal drugs or controlled substances?

Do you drink alcoholic beverages? If so, what and how often?*

Please correct your Do you drink alcoholic beverages? If so, what and how often?

Have you ever been convicted of a DUI, driving while under the influence of alcohol? If yes, when and what were the circumstances?*

Please correct your Have you ever been convicted of a DUI, driving while under the influence of alcohol? If yes, when and what were the circumstances?

Do you use tobacco products? If so, what and how often?*

Please correct your Do you use tobacco products? If so, what and how often?

Have you ever received treatment for alcohol or substance abuse? If yes, please explain.*

Please correct your 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.*

Please correct your 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.*

Please correct your 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.*

Please correct your Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? If yes, please explain.

Please read the following carefully before signing this application:

I consent to and understand that:

The references and youth serving-organization(s) I listed may be contacted by mail, telephone, email, or in-person;
I am in no way obligated to perform any volunteer services;
Worcester Youth and Family Counseling Services’ Worcester Connects Program is not obligated to match me with a youth and may deny my application or close my match at any time, and to protect all participants’ confidentiality is not required to disclose reasons for doing so;
As part of the enrollment processes, I will be required to provide additional personal information, including completion of an in-person interview;
All applications will be given equal consideration regardless of race, age, sex, disability, marital status, sexual orientation, gender identity, religion or national origin;
By completing this form, you consent to and understand that a background check will be conducted for conviction and pending criminal case information and that it will not necessarily disqualify you from participation;
I understand that the information I provide in the enrollment process will be kept confidential unless disclosure is required by law;
I certify that all information I have provided or will provide to Worcester Youth and Family Counseling Services, including this application, is true, correct, and complete to the best of my knowledge. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would affect my application for a volunteer position. I understand that information contained on my application will be verified by Worcester Youth and Family Counseling Services. I understand that misrepresentations or omissions may be cause for my immediate rejection as an applicant or my termination as a volunteer.

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

Please correct your Signature.

Date

Please correct your Date.