Empire Mentorship Initiative Mentor Application

Birth Date

Month

Day

Year

Marital Status

Single

Married

Widowed

Divorced

Do you have a Driver's License?

Yes

Do you own a car?

Yes

Driver's License Number:

Driver's License Issuing State:

School/College/University

Major(s) / Field Of Study

Graduation Year

Month

Day

Year

School/College/University 2

Major(s) / Field Of Study 2

Graduation Year 2

Month

Day

Year

Are you Currently Employed

Yes

Are you Currently Enrolled in an Academic Institution?

Yes

What languages do you speak? / ¿Qué lenguas habla?

Have you ever been convicted of a crime?

Yes

If you have you ever been convicted of a crime, how many times?

One Time

Two Times

Three Times

Four or More

Have you ever spent time in jail, prison, or juvenile detention?

Yes

What previous experience do you have with youth and volunteering?

Have you previously served as a mentor?

Yes

Why are you interested in serving as a mentor?

Are you involved in any Other community activities (i.e. clubs, Organizations, etc.)?

Do you have any Concerns about being a mentor or regarding the mentoring relationship?

Are you confident you can commit at least one year and a minimum Of 4 hours monthly to a mentoring relationship?

Yes

Would you be willing to mentor a high-risk student?

Yes

Would you prefer a middle school or high school student?

Middle School Student

High School Student

Are there any issues I subjects in particular you would find difficult to deal with as a mentor? If so, please specify:

What days I times are you available to meet with a mentee? (keep in mind: the more available you are, the easier it will be to match you with a mentee.)

Personality Information: Please describe yourself (check all that apply):

Interests: Watch TV I Movies (give an examples)

Interests: Play Video Games (give an examples)

Interests: Play Sports (give an examples)

Interests: Listen to Music (give an examples)

Interests: Read (give an examples)

Interests: Other (please specify)

In which subjects are you knowledgeable and with which you would be willing to assist a student?

Please write a brief paragraph describing yourself

Faith Statement:

Please write a brief statement of your faith including your values, beliefs, and association with religion:

Church or Para-church Name:

(i.e. campus fellowship)

Church or Para-church Phone Number:

Church or Para-church Address:

Church or Para-church City:

Church or Para-church State:

Church or Para-church Zip:

Church or Para-church Pastor I Leader's Name:

In what ministry or ministries are you currently involved?

Name

Unrelated references who, having known you for more than one year, can affirm your capacity to serve as a positive role model for a student in our community:

Name 2

Unrelated references who, having known you for more than one year, can affirm your capacity to serve as a positive role model for a student in our community:

Application Consent

Yes

The information I am presenting in this application is true and Correct to the best of my knowledge. I hereby give the Primitive Christian Church / Vision Urbana Mentoring Initiative permission to contact my references concerning my qualifications to be a mentor. If appointed as a mentor. I to abide by stated rules and goals for the program and will fulfill my responsibilities to the best of my ability.

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Empire Mentorship Initiative Mentor Application