Youth Mentor Application

Step 1 of 5

Personal Information

Name

First Last

Gender

Ethnicity

Please list all members of your household

Employment History #1

Employer

Position Held

Dates of Employment

From-to (Month/Year)

Supervisor's Name

Title

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment History #2

Employer

Position Held

Dates of Employment

From-to (Month/Year)

Supervisor's Name

Title

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment History #3

Employer

Position Held

Dates of Employment

From-to (Month/Year)

Supervisor's Name

Title

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Application Questions

Why do you want to become a mentor?

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

What qualities, skills or other attributes do you feel you have that would benefit a youth? Please explain.

Can you commit to participate in the World Relief Youth Mentoring Program for a minimum of one year from the time you are matched with a cohort?

Are you available to meet with the group facilitators for 4 hours per month and have contact at least biweekly? Please explain any particular scheduling issues.

Describe your general health. Are you currently under a physician's care or taking any medications? If so, please explain.

How would you describe yourself as a person?

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

Have you ever used illegal drugs? If so, what sebstances were used and how often?

Are you currently using any illegal drugs or controlled subtances?

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?

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.

Have you ever been treated or hospitalized for a behavorial disorder? If yes, please explain.

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.

Are you willing to communicate regularly and openly with program staff, provide monthly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program?

Are you willing to attend an initial mentor training session and quarterly training sessions per year if matched?

Please read this carefully

I agree to the below.

I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.
I understand that the World Relief Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.
I understand I must submit all of the following completed items.

Signature

Date

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Youth Mentor Application

Personal Information

Employment History #1

Employment History #2

Employment History #3

Application Questions

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