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 McAfee, at emcafee@hsymca.org or 501-623-8803 x 122.

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