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MENTOR APPLICATION

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone

(###)

###

####

Home Phone

(###)

###

####

Employer

Job Title

Preferred mentor meet-up days & times

Preferred mentee grade level

Middle School

High School

No preference

APPLICANT QUESTIONS

Write a brief statement on why you wish to be a mentor.

Describe any special interests and hobbies, which may be helpful during our matching process.

(For example: chess, crafts, career interests, stamp collecting, sports, computers, art, crocheting, music, painting, etc.)

Do you have any previous experience mentoring or working with youth? If "yes", we'd love to hear about it. If "no", no worries, LEC is a great place to begin.

Can you commit to participate in the program for a minimum of one year?

Have you ever been convicted of a crime? If so, what were the circumstances?

Have you ever been investigated or convicted of child abuse and neglect? If yes, please explain.

Have you ever been investigated or convicted of sexual abuse of a minor? If yes, please explain.

Are you willing to communicate regularly and openly with program staff, provide monthly information regarding your mentoring activities and receive feedback regarding any challenges that arise during your participation in the program?

REFERENCES

Please provide two personal references (other than family members):

Personal Reference #1

First Name

Last Name

Phone

(###)

###

####

Personal Reference #2

First Name

Last Name

Phone

(###)

###

####

MENTOR RELEASE STATEMENT & CRIMINAL BACKGROUND CHECK AGREEMENT

Information shared in this section is confidential and will not be shared beyond the verifying agency.

Please list any other cities, states, and dates of residency during the past 10 years.

Social Security Number

Current Driver's License No & Issuing State:

I understand that LEC program staff reserves the right to terminate any mentor from the Program at any time for any reason. I understand that program meet-ups (between the mentor and the assigned mentee) will take place within the scheduled times, exclusively at the Program location or locations pre-approved by program staff. I understand that any relationship or contact established between mentor/mentee and family members beyond the organized and supervised activities of the Program are neither encouraged nor condoned. I give the Leadership Empowerment Center permission to conduct a legal/criminal background check and personal reference check to verify any and all information provided by me on this Program application, as part of the screening for entrance into the Program. Program staff has final right of acceptance of applicant into the program at their sole discretion. I have read the above Mentor Release Statement and agree to the contents. By typing my name below I certify that all statements in this application are true and accurate.