Mentor Application

Date:
All information on this form is kept confidential The information you provide is used
to match you with your mentee. Please provide as much information as possible.
1. Name: ____________________________________________________
2. Address(mailing/physical):_____________________________________
_____________________________________________________________
3. Telephone #: ___________________E-mail_______________________
4. Current Employer:____________________________________________
5. Work Number__________________Can we contact you at work_______
6. Birth Date: _____________
7. What experience have you had working with youth? _________________
___________________________________________________________________

7. What recreational activities do you participate in?

___________________________________________________________________

8. What other interests/hobbies do you have?

___________________________________________________________________

9. Why are you interested in becoming a mentor? _____________________

______________________________________________________________

10. Why do you think you would be a good mentor? ____________________

___________________________________________________________________

11. I would like to work with a child aged ___, and preferably a M  or F .

12. What is the best day(s) of the week and time for you to meet with your mentee?
_________________________________________________________________

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 13. Person to be notified in case of an emergency:_______________________
Relationship to you_______________________________________________

15. Certifications: (please circle) CPR First Aid Life Guard

16. CONFIDENTIAL
Mentor Connector requires the following information from all volunteers working with
youth. Thank you for your help providing the safest environment possible for youth.

A. Do you use illegal drugs? Yes/No

B. Are there any pending criminal charges against you? Yes/No

C. Have you ever been convicted of a felony offense? Yes/No

A conviction may not necessarily disqualify you. Give offense, date and jurisdiction
__________________________________________________________________

D. Have you ever been charged with child neglect or abuse? Yes/No

E. Other than the above, is there any fact or circumstance involving you or your
background that could call into question your being entrusted with working with youth?

Yes/No

F. Please explain any “Yes” responses. Answering “Yes” may not necessarily disqualify
you.
_____________________________________________________________________

17. References:

Please list 3 names and phone numbers of people who know you well and can attest to
your character, skill and dependability. Please do not list a relative as your reference.

1. Name:__________________________ Phone number___________________

How do you know this person?________________________________________

2. Name:__________________________ Phone number___________________

How do you know this person?_________________________________________

3. Name: _____________________________ phone number_______________

How do you know this person?________________________________________

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 Please read the following carefully before signing this application:

I understand that this is an application for and not a commitment or promise to

volunteer.

I certify that I have and will continue to provide information throughout the
selection process that is true, 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 unfavorably affect my
application for a volunteer position. I understand that information contained on
my application will be verified, if necessary, by Mentor Connector contacting any
person or organization that may have information concerning me. I release and
agree to hold harmless from liability any person or organization who provides
information. I understand that misrepresentations or omissions may be cause for
my immediate rejection as an applicant for a volunteer position as a mentor or my
termination as a volunteer.

Signature ________________________________ Date:___________________

Please return to:

Mentor Coordinator
77 Woodstock Avenue
Rutland Vermont 05701

Or email to rebecca@mentorconnector.com

For questions about the application please call (802)775-3434

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Office use
Date Received________________

Referral Source_______________
Mentor Coordinator Notes: ____________________________________

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 Mentoring Fact sheet
Thank you for wanting to be part of our mentoring program. Here is some basic
information to get you started.

Programs:
School Based Programs: Site Based Mentoring with youth in Elementary Schools.
Spend your lunch hour reading and talking to a mentee. This is an hour a week program
based in the school. Mentors are not allowed to leave the school with their mentee.
Check with Mentor Connector office for participating schools.
Up2Us: Community based mentoring youth ages 8-18 years old
Mentors get together on their own to share fun activities they both enjoy. Matches
typically meet for one hour a week and they shoot hoops, play board games, share a
Pizza, walk in the park or just hang out talking. It doesn’t require a special occasion or
expensive activities, just a few hours to share things that you like to do.

Make the connection

o Willingness to volunteer for Just four hours a month (one hour a week)!
o A desire to want to serve as a coach, a guide and a role model for youth
o Personality traits that reflect patience, honesty, warmth and the ability to have
FUN!

We are here to help

Guidance from Mentor Coordinator
Access to materials
Support meetings/trainings

How to become a mentor

o Mentors must be 18 or older to apply
o Complete an application form
o Mentor Coordinator will contact you to set up an interview
o Agree to background and License check
o Meet your mentee and their family

Questions? Please contact The Mentor Coordinator at 775-3434 or

rebecca@mentorconnector.com

Share what you know, Mentor a child.