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Full Mentor Application
Mentor Application
Once your form is submitted a representative will contact you about next steps within 2 business days. If you have questions, please call 503-584-4865 NOTE- 1) WE ARE CURRENTLY ONLY ACCEPTING APPLICATIONS FOR SPORTS BUDDIES AND REENTRY ADULT MENTORING. FOR QUESTIONS ABOUT THESE PROGRAMS PLEASE CALL 503-584-4865. 2.) this application is for individuals who wish to volunteer as mentors. For any other volunteer positions please fill out the general volunteer application here: http://midvalleymentors.org/volunteer-form/
Name
First
Last
Email
Mailing Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
Cell Phone
Work Phone
Preferred Method of Contact
Email
Home Phone
Cell Phone
Work Phone
Emergency Contact
Emergency Phone Number
Date of Birth
MM
DD
YYYY
Gender
Male
Female
Race
Native American
African American
Asian / Pacific Islander
Hispanic / Latino
Caucasian
Multi-cultural
Other
Do you speak a second language (besides English)
Spanish
Other
How did you hear about our program?
*
Roadside Sign
Billboard
Bus Side
Bus Back
Mentoring.org
Hands On / United Way
Newspaper
Radio
Google Search
YouTube
Poster or Flyer
Community / Corporate Presentation
Volunteer / Career Fair
Word of Mouth
Craigslist
OR Mentors
Volunteer Match
Other
If you marked other, please list how you heard about us.
I am interested in the following volunteer opportunities:
*
Adult Mentoring
Sports Buddies
Mentoring Preferences
Mentoring Type Preference
*
One-on-One
Small Group (Sports Buddies or Adult Mentoring Only)
Age Preference
*
11-14
18-24
25-30
30 - 35
35-40
40+
No Preference
Driving Information
Do you have a valid driver's license?
*
Yes
No
Issue Date
State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Do you own a car?
*
Yes
No
Is public transit available to you?
No
Yes
If yes, which bus line?
Education
Highest Level of Education
*
High School
Associate Degree
Bachelor's Degree
Graduate of Professional Degree
Some College
Other
Prefer Not to Answer
Degrees
Degree Date
MM
DD
YYYY
Name of College
Why are you interested in Mentoring?
*
I want to help people succeed
I want to make a difference in someone’s life
I want to give back to the community
Religious and spiritual reasons
Someone helped when I was younger
Other
Employment
Employer Name
Employer Phone
Employer Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Occupation
Title
Volunteer Experience
Describe any your volunteer experience you've had (if any).
Do you have prior Mentoring experience?
*
Yes
No
If yes, what was the program name?
Program Start Date
Program End Date
Personal References
References may not be a family member. Students please include at least one profesor as a reference.
Reference #1: Name
First
Last
Phone
Reference #1 Email Address
Relationship
Years Known
Reference #2: Name
First
Last
Phone
Reference #2 Email Address
Relationship
Years Known
Reference #3: Name
First
Last
Phone
Reference #3 Email address
Relationship
Years Known
Mentoring Questionaire
Please answer the following questions to help us make the best possible mentor-mentee match. All information will be used to factor your compatibility with potential mentees.
Salem Area
South Salem
West Salem
North Salem
East Salem
Keizer
Please indicate all areas you are willing to volunteer in.
Rural Marion County
Woodburn / Gervais
Aumsville / Stayton
Jefferson
Silverton
Please indicate all areas you are willing to volunteer in.
Do you have a preference of the ethnicity of your Mentee?
African American
Asian Pacific Islander
Caucasian
Hispanic / Latino
Multi-cultural
Native American
Other
No Preference
Mentee Background: Willing to be matched with mentees from a home environment or background involvement with
Substance Abuse
Emotional Abuse
Physical Abuse
Sexual Abuse
Mentee Religious Affiliation Preference
Restriction
Preference
None
If restriction or preference, please explain
Mentee Sexual Orientation Preference
Restriction
Preference
None
If restriction or preference, please explain
Do you have a restriction or preference on the sexual orientation of the Mentee's parents?
Restriction
Preference
None
If restriction or preference, please explain
When are you available to conduct mentoring activities?
Are there any times throughout the year when you may be unavailable to meet with a mentee weekly? (i.e. summer, vacation time) If YES, please indicate dates and the duration
What are your interests?
Interests (check all that apply)
Arts/Crafts
Dance
TV
Computer / Video Games
Shopping
Reading
Movies
Play Instrument
Travel
Cooking / Eating Out
Listening to Music
Playing Sports
Baseball
Basketball
Football
Golf
Hockey
Lacrosse
Soccer
Softball
Tennis
Volleyball
Other
Watching Sports
Baseball
Basketball
Football
Golf
Hockey
Lacrosse
Soccer
Softball
Tennis
Volleyball
Other
Cultural Events
Concerts
Museums
Theather
Other
Outdoor Activities
Biking
Canoeing / Boating
Hiking
Ice-skating
Rollerblading
Walking
Other
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