Seeds Of Hope Men's Outreach
Seeds Of Hope Men's Outreach

Mentor Application

SEEDS OF HOPE MENTOR APPLICATION.docx
Microsoft Word document [17.2 KB]

SEEDS OF HOPE MENTOR APPLICATION

(Please type or print)

Thank you for your interest in participating in Seeds of Hope Mentor Program.

 

First we want to know more about you and your interests and skills so we can better match the interests of mentors and mentees. Please take the time to answer the following questions. All information that you provide will be kept confidential.

Date___________________________

First Name: ____________ Middle Initial:________Last Name:_______________        Date of Birth___________

Address_________________________________________________

City______________________________State_______________Zip____________

Employer________________________Occupation__________________________

Work Address_______________________________________________________

City______________________________State________________Zip___________

Work phone:_________________________E-mail Address:__________________

Home phone:_________________________ Cell Phone:_____________________

List the address where you have lived for the last 10 years (begin with the most recent). Use back of page or separate sheet if more space is needed.

Dates: From___________________________to_______________________

Address__________________________________________________________

City_____________________________State____________Zip_______________

Dates: From___________________________to_______________________

Address__________________________________________________________

City_____________________________State____________Zip_______________

References:

To ensure the safety of the program participants, Seeds of Hope will be checking personal references on every applicant. Please list three people who know you and well and can attest to your character, skill and dependability. 

Reference 1:

First Name:__________________________Last Name:______________________

Phone:______________________________Relationship:____________________

Reference 2:

First Name:__________________________Last Name:______________________

Phone:______________________________Relationship:____________________

 

Reference 3:

First Name:__________________________Last Name:______________________

Phone:______________________________Relationship:____________________

 

 

 

 

  • On back of this application or a separate sheet of paper, write a brief statement on why you wish to be a mentor in the Seeds of Hope Mentoring Program.
  • On back of this application or a separate sheet of paper, describe special interests or hobbies that may be helpful in matching you with a mentee (e.g. cooking, crafts, career, interests, games, sports, computers, art, languages, music, painting, etc.). 

 

 

Mentor Release Statement

I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of the Seeds of Hope Mentoring Program. I understand that I will attend a training session, keep in regular contact with my mentee and communicate with the staff regularly during this period. I am willing to commit to one year in the program and then may be asked to renew for another year.

I have not been convicted of (a) any felony of any kind, or any misdemeanor involving (b) harm or threat of harm to another person, (c) controlled substances, (d) acts of a sexual nature, or (e) cruelty to animals. I am not under current indictment. Further, I hereby fully release, discharge and hold harmless the Seeds of Hope program, participating organizations and all of their employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs and expenses which may be or may at any time here after become attributable to my participation in the Mentoring Program.

I understand that the Seeds of Hope Staff reserves the right to terminate a mentor from the program. The program takes place only at Seeds of Hope and does not encourage or approve of relationships established between mentor/mentee and family beyond the organized and supervised activities of the program. I give permission for program staff to conduct a criminal background check as part of the screening for entrance into the program. This includes verification of personal and employment references as well as a criminal check with the authorities. Program staff has final right of acceptance of applicant into the program and reserves the right to terminate a mentor from the program at any time. I have read this Release Statement and agree to the contents. I certify that all statements in this application are true and accurate.

 

_____________________________________        __________________________

(Mentor Signature)                                                           (Date)

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