Ally Application & Questionnaire

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Email *

First Name *

Last Name *

Street Address *

City, State, Zip *

Date of Birth *

YYYY

Phone Number *

Number of Children and Ages of Children *

What do you do for a living? *

Are you active in a local church? If so, in which church? *

Have you ever been convicted of a crime? *

Yes

If yes, please explain. *

Do you have any objection to Mommies Matter ordering a background check on you? *

Yes

Do you have any objection to Mommies Matter pulling your driving record? *

Yes

Why do you want to be an Ally? *

Can you fulfill the key time commitments the role of an Ally requires? *

Support Person during birth (if applicable), Attend her Baby Shower (if applicable), Maintain weekly contact, Attend bi-monthly Enrichment Gatherings, Attend Ally Training.

Yes

Other:

Do you have any prior mentoring experience? *

Yes

Other:

Please describe any previous experience you have working with low-income families. *

What are your hobbies/special skills? *

References

Please provide the contact information for three individuals to provide a character reference.

Reference #1 Name *

Reference #1 Phone *

Reference #1 Email *

What is your relationship to Reference #1? *

Reference #2 Name *

Reference #2 Phone *

Reference #2 Email *

What is your relationship to Reference #2? *

Reference #3 Name

Reference #3 Phone

Reference #3 Email

What is your relationship to Reference #3

I agree to allow Mommies Matter to confirm all information listed and to conduct a federal and state criminal background check. *

Yes

E-SIGNATURE

I understand that by placing my full name in the below field it is as if I am freely and voluntarily signing this statement of release as if it was a paper document.

My Name (E-Signature) *

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