ALOH Breaking Boundaries Mentor Application
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First & Last Name *
Street Address *
Phone Number *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Gender *
Ethnicity *
Emergency Contact (Name, Number) *
Highest Education Level (Major) *
Availability 
Before school
After school
Lunchtime
Mornings
Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Own car? *
Driver's License? *
If yes, Driver's license number, state, expiration date.
Current Employer / Occupation *
Have you ever worked with you? If so, Please explain in what capacity. *
What is your leadership style? *
Why do you feel you would be a good mentor? *
Reference #1 (Name, phone, email, relationship) *
Reference #2 (Name, phone, email, relationship) *
Skills / Interests *
Required
T-Shirt Size *
Briefly explain previous volunteer experience. *
Why do you want to be a mentor in this program? *
Briefly describe your expectations of the mentoring program. *
Do you have any physical problems or limitations? *
Are you receiving treatment for any medical issues? *
Are you currently taking any type of medications? If yes, please explain. *
Do you have any known allergies or adverse reactions to medications? If yes, please explain. *
Have you ever been convicted of a crime, child abuse or neglect? If yes, please explain. *
Have you ever been charged with a sex crime/offense? If yes, please explain. *
Have you ever had CPS (Child Protective Service) history? If yes, please explain.  *
I give my informed consent and permission to have a criminal background check and
sexual offender’s registry completed by A Legacy of Hope Inc.
*
I agree to follow all the mentoring program guidelines and understand that any violation
may result in suspension and/or termination of the mentoring relationship.
*
I hereby acknowledge that my mentee may be transported in my personal vehicle while
participating in the mentorship program, and that such transportation is voluntary and at your
own risk.
*
I release the ALOH Breaking Boundaries Mentoring Program of all liability of injury,
death, or damages to self, my mentee, family, estate, heirs, or assigns that may result from
participation in the program, including but not limited to transportation, and hold harmless any
mentor, program staff, or other representatives, both collectively and individually, of any injury,
physical or emotional, other than where gross negligence has been determined.
*
By submitting this application, I understand that I must return all the following completed items along with this application, and
any incomplete information will result in the delay of this application being processed. I attest to the truthfulness of all information listed on this application and agree to all of the
above terms and conditions.
*
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