BMF Mentor Program Application
Broken Men Foundations Mentor Application.
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First Name *
Last Name *
Gender *
Date of Birth *
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Social Security Number *
Employer *
Employmnet Start Date *
Ethnicity *
Are you married? *
Do you have Children? *
Number and age of Children? *
Second Spoken Language
Home Address *
City *
State *
Zip Code *
Home Phone *
Work Phone *
Cell Phone *
Email Address *
Level of Education *
Are you currently enrolled in any education or training program?
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If yes explain
How would you describe your communication style?
 *
Required
Do you have any specific training or experience in dealing with any of the following youth issues? *
Required
Please describe your training or experience.
List any clubs or organizations of which you are currently a member.
Are there any particular problems you would prefer not to handle as a mentor?
Write a brief statement explaining why you have chosen to participate in the mentor program.
Which of the following activities do you enjoy participating in or watching?
Is there anything else you would like us to know about you? If yes, please explain.
Reference 1 (Include Name, Address, ZIP Code, Phone Number, Relationship, Years Known) *
Reference 2 (Include Name, Address, ZIP Code, Phone Number, Relationship, Years Known)
Reference 3 (Include Name, Address, ZIP Code, Phone Number, Relationship, Years Known)
I declare that all of the statements made in this application are true, complete, and correct to the best of my knowledge.
 *
I will adhere to all volunteer policies implemented by BMFYA.
 *
I will notify BMFYA if I must terminate my mentor position for any reason.
 *
I will notify BMFYA if I am unable to attend a previously scheduled meeting or event.
 *
I will not willfully arrange contact with my student off the designated property unless previously agreed to by management.
 *
I will not drive my student in my car.
 *
I understand that BMFYA will terminate my relationship with my student if I violate any of the above policies.
 *
I understand that the Broken Men Foundation Youth Academy Mentoring Program requires all volunteers to provide a recent criminal background check and that failure to do so may result in rejection as a mentor.
 *
I certify that the information provided in this application is true and accurate and understand that knowingly providing false information is grounds for dismissal.
 *
Confidentiality and Non-Use Agreement

Mentors may not copy, share, distribute, or use any confidential information, curriculum, training materials, participant information, or other property belonging to the Broken Men Foundation without written permission.

Mentors are also prohibited from using the Foundation’s materials or information to create or support a competing program. Violations may result in immediate removal and possible civil legal action.

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