Mentor Screening
Please complete this questionnaire, upon submitting you will be contacted with next steps.
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Part I. Mentor's Personal Info
First Name
Last Name
Mobile Phone Number
Language Spoken *
Date of Birth
Address (Street, City, State, Zip Code)
How long have you been living at this address?
Do you anticipate moving for any reason within the next year? If yes, please provide more deatails.
Race/Ethnicity (optional)
Languages spoken *
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Present Place of Employment
How long have you been working there?
Work Address
Have you ever been convicted of a crime? If so, list date(s) and charges of which you were convicted.
Do you currently have any criminal charges pending against you? If so, please describe them.
Part II. Mentor Program Details
How did you hear about this mentor program?
Have you ever been a mentor? If so, where and for how long?
Why do you want to become a mentor?
Part III. Mentor's Interests and Skills
To help us match you with a youth in our program, we would like to know a little
about your interests.
Which of these activities do you enjoy?
If you selected any of these activities, please provide more details as to what sport, activity, game, or interest/skills?
Do you have other special skills and experience? (For example, knowledge of sign language, experience working with adolescents, experience helping children learn to read.)
Part IV. Matching Preferences
Are there some types of children or youth whom you would prefer to mentor—or for whom you feel you would be a particularly successful mentor? (For example, someone who is shy, someone who has trouble managing his or her anger, someone who loves to draw, someone who loves sports, someone with a learning disability, someone with a physical disability.)
Are there some types of children or youth with whom you might have difficulty or would prefer not to mentor?
What kinds of support and assistance can the program offer that will be most helpful to you?
Part V. Mentor's References
Please list the names, addresses, and phone numbers of three people you want to use references. They must be people who have known you for at least one year. Please do not list relatives.
1. Reference's Full Name
1. References Address (street, city, state, zip code)
1. Reference's Phone Number
1. How long have you known this person? What is your relationship?
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