Mentor Form

How did you find out about our youth? How did you find out about our youth? Church Mentor Website/Social Media Site Board Member/Staff Other

Name of Church

Name of Mentor

Name of Board Member or Staff

Name Other Source

First Name

Last Name

Address

City

State

Zip

Your Ethnicity Your Ethnicity American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other

Other Ethnicity

Email

Home Phone

Cell Phone

Date of Birth

Age

Family Structure Family Structure Single Married Divorced Separated

Name of Spouse

Do you have Children?

Would you agree to have us check your name through federal and state criminal records of child abuse and neglect proceedings? Would you agree to have us check your name through federal and state criminal records of child abuse and neglect proceedings? Yes No

Social Security Number

This Information is Required for background check

Do you have a valid Driver’s License? Do you have a valid Driver’s License? Yes No

Expiration Date

State

DL/Identification Number

Do you have current vehicle insurance as required by Texas law? Do you have current vehicle insurance as required by Texas law? Yes No

Occupation

Company

Work Phone

List any special interests, skills, or hobbies you have

List examples of any prior volunteer experience

Please circle the words that describe your personality Please circle the words that describe your personality Spiritual Sensitive Quiet Outgoing Adventuresome Happy Shy Talkative Confident Moody Nervous Friendly Other

Other Personality descriptions

If you agree to become a mentor, you will be asked to agree to the following basic requirements If you agree to become a mentor, you will be asked to agree to the following basic requirements To attend 2 hours of Mentor Orientation and Training before you will be considered for a one-on-one match with our youth. To maintain weekly contact with your mentee either in person or by phone. To be dedicated and dependable in trying to assist your teen to achieve success in their educational and emotional development.

Promise Rose reserves the right to accept or decline volunteers based on the information gathered. For reasons of confidentiality Promise Rose will not share this information or reasons of denial with any applicant. I certify that the information I have supplied is correct to the best of my knowledge. I give permission to contact the references provided and to complete a background check and a release of my motor vehicle insurance. Promise Rose reserves the right to accept or decline volunteers based on the information gathered. For reasons of confidentiality Promise Rose will not share this information or reasons of denial with any applicant. I certify that the information I have supplied is correct to the best of my knowledge. I give permission to contact the references provided and to complete a background check and a release of my motor vehicle insurance. Yes No

Reference (1) Full Name

Address

City

State

Phone

Relationship

Reference (2) Full Name

Address

City

State

Phone

Relationship