Reach & Rise 1:1 Mentor Application
Thank you for your interest in becoming a mentor with the Reach & Rise mentoring program. It is a great way to make a difference in a young person’s life. This application is designed to provide information to help us match you with the most appropriate child and your answers will be kept confidential. For security & safety purposes, all mentor applicants will need to have fingerprints or background checks completed and cleared before being matched with a youth. Also, a free 15-hour training in therapeutic mentoring methods and program policies/practices is provided in small, manageable chunks to prepare mentors for their work as volunteers within the program. If you have any questions, please contact the 1:1 Program Director, Elan Kesilman, at ekesilman@hsymca.org or 501-623-8803 x 108.

http://www.hsymca.org/Reach_And_Rise/
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Today's Date *
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Full Name *
Gender *
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Date of Birth *
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Street *
City *
Zip Code *
Home Number
Work Number
Cell Number
Email *
Best Way to Be Contacted
Best Time to Be Contacted
Occupation
How did you hear about us?
Do you have any felony convictions? *
Required
Have you ever abused or molested a child? *
Required
Do you have a clean driving record? *
Required
If you have a car, can you provide proof of liability insurance? *
Required
Why do you want to become a mentor? *
Would you be a positive role model to a child? What qualities do you have that will help mentor a child?
Why do you think children “act out” or get in trouble?
Do you have any experience working with, volunteering, or spending time with youth? If yes, explain:
Please describe any other volunteer experiences you have:
Do you have any academic pursuits/experience that is related to working with youth? If yes, explain:
Who was a mentor for you as a child? What qualities did they have that helped you?
Please describe your relationships with your family (e.g. parent(s)/guardian(s), siblings, etc.) both past & present. Include how you were disciplined as a youth and by whom.
Please describe your relationship with a best friend and/or significant other?
Please describe past and current patterns of drug and alcohol use:
What are some of your interests & hobbies (things you would like to do with your mentee)?
Do you have a preference as to the age, gender or ethnicity of the youth you’d work with?
Personal Reference #1 (NAME, PHONE, E-MAIL, RELATIONSHIP TO YOU? HOW LONG HAVE YOU KNOWN THIS PERSON?) *
Personal Reference #2 (NAME, PHONE, E-MAIL, RELATIONSHIP TO YOU? HOW LONG HAVE YOU KNOWN THIS PERSON?) *
Professional Reference #1 (NAME, PHONE, EMAIL, RELATIONSHIP TO YOU? HOW LONG HAVE YOU KNOWN THIS PERSON?) *
Professional Reference #2 (NAME, PHONE, E-MAIL, RELATIONSHIP TO YOU? HOW LONG HAVE YOU KNOWN THIS PERSON?) *
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