Full Mentor Application

Name

FirstLast

Email

Mailing Address

Street AddressCityStateZip 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

Do you speak a second language (besides English)

Spanish
Other

How did you hear about our program?*

I am interested in the following volunteer opportunities: (If you choose Mentoring, you will need to fill out a secondary form. The link will appear on the thank you page after you submit this form.)*

Mentoring Preferences

Mentoring Type Preference*

One-on-One
Couples (2:1 or 2:2+)

Population Preference

Children of Prisoner
Youth on Probation
Adult Offenders

Age Preference*

Location Preference

Site based
Community based

Driving Information

Do you have a valid driver's license?*

Yes
No

Issue Date

State of Issue

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*

Degrees

Degree Date

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 AddressCityStateZip Code

Occupation

Title

What is your work or school schedule? (Days / Times)

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

FirstLast

Phone

Address

Street AddressCityStateZip Code

Relationship

Years Known

Reference #2: Name

FirstLast

Phone

Address

Street AddressCityStateZip Code

Relationship

Years Known

Reference #3: Name

FirstLast

Phone

Address

Street AddressCityStateZip Code

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

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.

Polk County (JEM program only)

Dallas
Monmouth
Independence

Please indicate all areas you are willing to volunteer in.

Age Group

Please indicate all age groups you would like to volunteer with.

Do you have a preference of the ethnicity of your Mentee?

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

What is your availability?

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)

Playing Sports

Watching Sports

Cultural Events

Concerts
Museums
Theather
Other

Outdoor Activities

Inspire

Enage

Connect

Mentor Application

Mentoring Preferences

Driving Information

Education

Employment

Volunteer Experience

Personal References

Mentoring Questionaire

What are your interests?

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