Click here to register online CHILDREN OF PROMISE MENTOR PROGRAM
Mentor Application Date: _____/____/_____
Personal Information County: □ South Fulton □ Fayette □ Henry □ Clayton
Name:________________________________________________________
Street Address: ____________________________ Apt _____Bldg________
City: ________________ Zip: ___ Date of Birth_____/_____/_____
Age _________
Contact Phone # ____________ Cell:___________ Other ______________
Email __________________________@____________________
Please list all members of your household:
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Employment History
Please provide employment information for the past five years, with most recent position held first. If more space is needed use an extra sheet of paper.
Employer: ____________________________________Phone: _____________________
Address: ________________________________________________Zip: ___________
Supervisor’s Name: ____________________________Title: ______________________
Date of Employment (m/year): ______to _______ Position Held______________________________
Employer: ____________________________________Phone: _____________________
Address: _______________________________________________________________Zip: ___________
Supervisor’s Name: ____________________________Title: ______________________
Date of Employment (m/year): ___________to _________ Position Held______________________________
Personal References
Please list the names, addresses, and phone numbers of three people you would like to use as character references (only people you have known for at least a year). Include at least one relative. Any information Tennis in the ‘Hood, Inc. Mentoring Program gathers from these references will be held as confidential and will not be released to you, the applicant.
1. Relative’s Name: ____________________________Phone: _____________________
Address: ________________________________________________________________ Zip_____________
Relationship: ____________________________Years Known: ____________________
2. Reference Name: ____________________________Phone: _____________________
Address: ________________________________________________________________ Zip_____________
Relationship: ____________________________Years Known: ____________________
3. Reference Name: ____________________________Phone: _____________________
Address: ________________________________________________________________ Zip_____________
Relationship: ____________________________Years Known: ____________________
MENTOR PERSONAL ASSESSMENT
Why do you want to become a mentor?
What do you think are your strengths?
What do you think are your weaknesses?
Do you currently use any alcohol, drugs or tobacco? O yes O no
Have you ever been arrested ? O yes O no
Have you ever been treated or a mental condition? O yes O no
Have you ever been hospitalized for a mental condition? yes O no
Have you ever abused or molested a youth? O yes O no
Do you have any experience working with children? O yes O no
If so how will it help you in working with your mentee?
Who else in your household might be present at any given time when you are with your mentee?
Please circle all the activities that interest you
Biking Camping Science Soccer Computer Games
Cooking Library Hiking Baseball Arcade Games
Boating Music Basketball Football Photography
Yoga Golf Parks Amusement Parks
Text Messaging
Gardening Animals Eating out Scrap booking Talking on the phone
Fishing Movies Reading Sewing Arts and Crafts
Board Games Drawing Dancing Board Games Reading
Other:
Please indicated age group you are interested in mentoring? 4-7 8- 11 12-13 14-15 16 all ages
Do you speak any other language than English?
If yes which ones?
Would you be willing to work with a child with disabilities?
What are some of your favorite things you like to do with other people?
What are some of your favorite subjects to read about?
What is your job/career?
How did you choose that field?
What is one goal you have set for the future?
If you could learn something new, what would it be?
What person do you most admire? Why?
Describe your ideal Saturday?
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I understand I must return this completed application , a copy of my valid driver’s license and proof of auto insurance and attend a mentor training to begin the application process . I also understand that any incomplete information will result in the delay of my application being processed.
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
_________________________________ _______________
Signature Date
Mentor Eligibility Requirements
YOU MUST MEET ALL OF THESE REQUIREMENTS TO BE CONSIDERED FOR A MENTORING POSITION:
o Be at least 18 years of age
o Be willing to adhere to all Children of Promise Mentoring Program policies and procedures
o Agree to a one-year commitment to the program
o Commit to spending a minimum of one hour a week with the mentee
o Complete the screening procedure
o Agree to attend mentor training as required
o Be willing to communicate regularly with the program coordinator and submit monthly meeting and activity information
o Have access to an automobile or reliable transportation
o Have a current driver’s license, auto insurance, and good driving record
o Have a clean criminal history
o Have never been accused, arrested, charged, or convicted of child abuse or molestation
o Not be a convicted felon. If the applicant has been convicted of a felony then they may be considered only after a period of seven years with a demonstration good behavior and an appropriate and corrective attitude regarding past behaviors.
o Not be a user of illicit drugs
o Not be currently in treatment for substance abuse. If a substance abuse problem has occurred in the past the applicant must have completed a non-addictive period of at least five years of the screening process.
I meet the above stated requirements and I agree to follow all the stipulations of this program as well as any other conditions as instructed by the program coordinator at this time or in the future.
_______________________________________ ________________
Signature Date
PLEASE READ THIS CAREFULLY BEFORE SIGNING:
Please initial the following
___________ I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.
___________I understand that Children of Promise Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.
___________ (optional) I agree to allow Children of Promise Mentoring Program to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
I understand I must return all of the following completed items along with my application, and that any incomplete information will result in the delay of my application.
o Copy of your Valid Driver’s License
o Copy of Proof of current valid insurance
o Background Release Form ( Criminal/ Child Abuse and Neglect/Sexual Offender)
o FBI Background Clearance Release Form
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