New Mentor Application
Please contact us at friendchips@essexchips.org if you would like to submit a print or PDF copy of this form, or have other questions about the FriendCHIPS Community Youth Mentoring Program. Thanks for your interest in helping youth in your community!
Name *
Phone Number *
Email Address *
Occupation *
Address *
Best Time to Contact You *
How did you hear about FriendCHIPS? *
Please list what days and times you would be available to volunteer. *
Please list any medical restrictions, requirements, allergies, etc. *
Please let us know who to contact in the case of an emergency (including phone, email, etc.) *
(1/3) Please list three personal or professional references (including phone, email, relationship) *
(2/3) Please list three personal or professional references (including phone, email, relationship) *
(3/3) Please list three personal or professional references (including phone, email, relationship) *
If you prefer working with a youth of a certain gender identity, please list the identity.
Do you prefer working with an introverted or extroverted child? *
If you prefer working with youth of a certain age group, please list the age group.
Please list any languages you speak other than English.
Please list your hobbies and interests. *
What kinds of activities would/do you enjoy doing with a young person? *
Describe what you feel a mentor’s role can be. *
What interests you about becoming a mentor? *
What qualities do you have that would make you a good mentor? *
Who has served as a role model for you and why? *
What do you enjoy about young people? *
What do you find challenging about young people? *
Please list any experiences you’ve had working with young people (paid or volunteer): *
Applicant's Certification
Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance? If yes, please email us an explanation. *
Are you under current indictment or has a district/county attorney ever accepted an official complaint for any of the offenses in the above question? If yes, please email us an explanation. *
May we reproduce photos in which you appear in Essex CHIPS promotional or educational materials? *
By submitting, you indicate that you agree with the following: I agree to abide by the rules and regulations of the program and fully discharge the FriendCHIPS Youth Mentoring Program and Essex CHIPS from liability and claims resulting from my volunteerism. I certify to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and on subsequent mentor application forms, 
is grounds for dismissal.
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