Take Stock in Children Mentor Application – Duval

Step 1 of 10 - Mentor Information

Mentor Information

Name(Required)

First Last

Salutation

Date of Birth(Required)

MM slash DD slash YYYY

Social Security Number(Required)

Driver's License #

Gender

Male

Female

County(Required)

Preferred School / Location(Required)

Employer(Required)

Title(Required)

Employment Start Date

MM slash DD slash YYYY

Are You A Take Stock In Children Graduate?(Required)

Yes

I heard about the TSIC program and want to become involved:

Yes

How Would You Describe Your Communication Style? (choose one)(Required)

Friendly & Outgoing

Usually wait to be approached by someone new

Reserved until I get to know someone new

I Am Interested In Becoming A Mentor Because (check all that apply)(Required)

I think I have the personality and abilities to be a good mentor

I overcame difﬁculties growing up and would like to help someone else

I have the time to give

I think I’d be a positive role model

I like children

I am interested in making a difference in the life of a child

I believe in the value of mentoring

I wish I had a mentor when I was a teenager

List Any Clubs Organizations Of Which You Are Currently A Member

Are There Any Particular Problems You Would Prefer Not To Handle As A Mentor?

Is there someone in particular you would like to be matched with?

Background Information

Ethnic Group (check one)(Required)

American Indian/Native American

Asian

Hispanic

African American

Caucasian

Other

If Other Please Specify

Age Category(Required)

18-30

31-40

41-50

51-60

61+

Are you married?(Required)

Yes

Do you have children?(Required)

Yes

Number of Sons & Their Age

Number of Daughters & Their Age

Second Languages Spoken

When you were a teenager, to what income group did your family belong?(Required)

Low Income

Middle Income

High Income

Contact Information

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone(Required)

Work Phone

Cell Phone

Email(Required)

Career / Education Information

Highest Education Completed (check all that apply)(Required)

Some School, Not a high school graduate

GED

High School Graduate

Associates Degree

Technical / Vocational Certificate

Bachelor's Degree

Master's Degree

Doctorate

Other

Associates Degree In & Name Of School

Technical / Vocational Certificate In & Name Of School

Bachelor's Degree In & Name Of School

Masters Degree In & Name Of School

Doctorate In & Name Of School

If Other Specify

Are you currently enrolled in any education or training program?(Required)

Yes

If Yes, Please Specify

Training Or Experience

Do you have any speciﬁc training or experience in dealing with any of the following youth issues: (check all that apply)

Drug Awareness

Teen Pregnancy

Teen Violence

Sex / Abstinence

Other

If you selected issue(s) from the list above, please explain:

Activities

Which Of The Following Activities Do You Enjoy Participating In Or Watching? (Check all that apply)

Sports

Handicrafts

Outdoor Life

Mechanics / Science

Literature

Pop Culture (Movies, TV, etc)

Collecting

Other

If you selected an activity, please explain:

Applicants Signature

Consent(Required)

The undersigned acknowledges and agrees that 1) he or she is not obligated, if called upon, to perform the volunteer services herein applied for; 2) Take Stock in Children is not obligated to assign or actively seek to assign her or him a Take Stock in Children student; 3) as part of the Take Stock in Children matching process, additional information may be requested from the applicant, and 4) Take Stock in Children reserves the right at all times to terminate any match between any volunteer mentor and student for whatever cause. I declare that all of the statements made in this application are true, complete and correct to the best of my knowledge.

Signature

Date

Approval For Below Statements

As a mentor in the Take Stock in Children program, I will always act in a behavior that is in the best interest of my student. Accordingly, I pledge to each of the following volunteer policy statements. Please initial your approval next to each statement.(Required)

I will adhere to all volunteer policies of my local school district.

I will notify Take Stock in Children if I must terminate my mentor position for any reason.

I will notify my student or his or her school liaison or the Take Stock in Children Student Advocate if I am unable to attend a previously scheduled meeting.

I will not willfully arrange contact with my student off school property and not under the supervision of Take Stock in Children or school ofﬁcials.

I will not drive my student in my car.

I understand that Take Stock in Children will terminate my relationship with my student if I violate any of the above policies

References

Please print COMPLETE name, address, and relationship of three people. They must have known you for at least 2 years. Each should be in a position to evaluate your qualiﬁcations as a mentor. Please do not include family members, current boyfriends, girlfriends, or ﬁancées as references.

Reference One

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Relationship(Required)

Years Known(Required)

Reference Two

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Relationship(Required)

Years Known(Required)

Reference Three

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Relationship(Required)

Years Known(Required)

Are you currently employed?

Yes

Work Reference: If you are currently employed, please print the name and address of your work supervisor.  If employed less than 6 months, the previous employer.

Liability Release / Consent For Release Of Information

I do hereby afﬁrm the above information is true. I understand if denied acceptance into a mentoring program, no reason for denial will be given. I hereby consent to(Required)

to release information to other entities, agencies, or individuals. I hereby release Take Stock in Children from any liability whatsoever for any information released or any acts or omissions connected with this application. I understand and consent to Take Stock in Children examining any and all available records or information from any source, to include but not be limited to criminal records. I hereby allow Take Stock in Children to release any information compiled from my interview, references, or other sources pertaining to my application to become a mentor to Take Stock in Children. Take Stock in Children will use this information for the purpose of evaluating my ability to meet the initial criteria to serve as a mentor with a mentoring agency. I hereby release  Take Stock in Children from any liability, debt, claim, suit, or obligation of any nature whatsoever should any information be obtained by any other individual, party, or entity of any nature whatsoever.(Required)

Date

Name

How did you hear about us?

Take Stock in Children Mentor Application – Duval

Mentor Information

Background Information

Contact Information

Career / Education Information

Training Or Experience

Activities

Applicants Signature

Approval For Below Statements

References

Please print COMPLETE name, address, and relationship of three people. They must have known you for at least 2 years. Each should be in a position to evaluate your qualiﬁcations as a mentor. Please do not include family members, current boyfriends, girlfriends, or ﬁancées as references.

Reference One

Reference Two

Reference Three

Liability Release / Consent For Release Of Information

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