Personal Information:

Name: Gender: Male Female

Address: City:

State: ZipCode:

Telephone(Home): Telephone(Cell):

Email: Drivers License#:

Date of Birth: Place of Birth:

Ethnicity: Number of Children:

Marital Status: Single Married Divorced Widowed

Emergency Contact: Relationship:

I prefer to receive calls at: Home Business Cell

Education/Experience

Grade Completed: Degree:

Major: Year:

Languages you speak other than English:

Employment

Current Employer: How Long?

Address: City:

State: ZipCode:

Position: Telephone: Email:

Church Affiliation

Are you a member of HTCF? Yes No

Will school-based mentoring be your primary ministry? Yes No

If no, what is your primary ministry?

Mentoring Information

Why do you want to become a mentor?

What challenges do you think young people face today that they need help with the most?

Why do you think you can help children or youth by mentoring?

As a child, did you have a mentor? Yes No

If yes, please describe your mentor:

Have you participated in a mentoring program before? Yes No

If yes, what program/organization?

When?

Will you be able to fulfill the commitments of the program---one hour per week for one school year? Yes No

Do you have any experience working with children? Yes No

If so, how will it help you in working with your mentees?

Mentoring a young person is a big responsibility and can change the lives of both the mentor and the mentee. What do you hope to gain from the experience and what do you hope the mentee gains form the relationship?

Availibility

Please select the times that you are available to mentor. (Mentoring sessions are in one hour increments, during school hours.)

Monday:A.M. only P.M. only Either A.M. or P.M.

Tuesday:A.M. only P.M. only Either A.M. or P.M.

Wednesday:A.M. only P.M. only Either A.M. or P.M.

Thursday:A.M. only P.M. only Either A.M. or P.M.

Friday:A.M. only P.M. only Either A.M. or P.M.

Please prioritize the following criteria you would prefer in a mentee(s).

Ethnicity:African-American Hispanic Caucasian Asian Doesn't Matter

Temperament:Active/Talkative Shy/Withdrawn Doesn't Matter

Grade Level:Elementary Middle High School Doesn't Matter

Background Check

Have you ever abused or molested a youth? Yes No

Have you been abused or molested as a youth? Yes No

If yes, please explain:

Have you ever been convicted of a felony or a misdemeanor? Yes No
If yes, please explain:

Have you ever been, treated or hospitalized for a mental condition? Yes No

If yes, please explain:

List names and daytime phone number of one personal and two professional references:

Name: Telephone:

Name: Telephone:

Name: Telephone:

I certify that all the information submitted by me on the application is true and complete to the best of my knowledge, and I understand that any false information, omissions, or misrepresentation of facts called for on this application may be cause for denial of my application or, if I am already an Action Harvest, Inc. volunteer, discharge at any time.

By signing this document, I agree to have the above references contacted. Please note that the above information will be held in your personal file and on the jobsite in case of an emergency.