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Mentor Application                                  Date: _____/____/_____


Personal Information County:    South Fulton     Fayette       Henry    Clayton



Street Address: ____________________________ Apt _____Bldg________

 City: ________________ Zip: ___    Date of Birth_____/_____/_____  

Age _________   


Contact Phone # ____________ Cell:___________ Other ______________


Email  __________________________@____________________


Please list all members of your household:




Relationship to Applicant






















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: ___________


Supervisorís Name: ____________________________Title: ______________________


Date of Employment (m/year): ______to _______

Position Held______________________________


Employer: ____________________________________Phone: _____________________


Address: _______________________________________________________________Zip: ___________


Supervisorís 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 ĎHood, Inc. Mentoring Program gathers from these references will be held as confidential and will not be released to you, the applicant.


1.  Relativeís 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: ____________________






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



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?




I understand I must return this completed application , a copy of my  valid driverís 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





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 driverís 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 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 Driverís 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