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Mentoring Volunteer Application
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The information in this application will help us match you with a protégé and will be kept confidential. If you have any questions, please stop and call our office at 316-262-8293.
First, middle, and last name
*
Your answer
Full address
*
Your answer
What part of town do you live in?
*
NW
NE
SW
SE
E-mail address
*
Your answer
Phone number
*
Your answer
How would you like us to contact you during daytime hours?
*
phone call
email
text message
Required
Would you like to receive our monthly newsletter to stay up to date with what's going on?
*
yes please, via email
yes please, via mail
no thank you
Employer
*
Your answer
Birthdate
*
Your answer
Social Security Number
Your answer
Family?
*
Single
Married
Divorced
Separated
Widowed
Spouse’s name
Your answer
Children Name(s) and Age(s)?
Your answer
High School attended
*
Your answer
Year graduated
*
Your answer
College & higher
Your answer
Church attending
*
Your answer
T-shirt size?
S
M
L
XL
2X
3X
4X
Clear selection
Emergency Contact (name & number)
*
Your answer
Do you have a valid Drivers License?
*
Yes
No
Do you have current vehicle insurance required by Kansas Law?
*
Yes
No
Do you have an age preference of child?
*
5-9
10-14
No Preference
N/A if Kinloch Price Boys Ranch
Which method of mentoring do you prefer?
School-based
Community-based
Kinloch Price Boys Ranch Residential
Not Sure
Clear selection
How did you hear about Youth Horizons?
*
employee of Youth Horizons
a friend/family member
my church
online (google search, social media, etc.)
a current mentor
Please provide a more specific answer to the above question: i.e. who, where, when?
Your answer
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