Mentor Log On

Mentoring Application Form

Please be sure to fill out this form completely and be sure to check off the AGREE TO STATEMENT BUTTON.

Click the submit application button when finished. You will be redirected to the success page if the form has been processed. If you do not fill out the form completely you will land on a page that will direct you to use you back button.

Thank you for your interest in this program.

Mentoring Application Form

First Name:

Last Name:

Mailing Address

Apartment Number and Street:

City: State: Zip:

Daytime phone: Time to call: AM:PM: Time:

Gender: MaleFemale

Date of Birth:

Select level of Education :

High School
Some College
Bachelor’s
Masters
PhD

e-Mail Address:

Race:

Please describe your personality (Select the most relevant):

Current Employer:

Occupation Title:

Are you involved in any other fraternal, social or civic activities? Yes No
If yes please list:

Please describe any special interests, which may be helpful in matching you and your student (e.g. chess, computers, sports, music, language, crafts, etc.)

Do you speak any language in addition to English? Yes No
If yes please list:

Do you have any previous experience mentoring/volunteering with youth? Yes No
If yes please list:

Have you ever been arrested? Yes No
If yes please explain:

What else would you like to tell about yourself?
Please type below:

What personality would you prefer your mentee to have?
Like yours? Unlike yours?

I prefer to mentor at:
	Travelers Aid (Homeless single mothers )
	Veteran
	Skills Program (Assisting as a job coach)
	Re-entry (Clients who were incarcerated)
	Tutoring (Adult Basic Education Program)

Personal References
Please list the name, address, and telephone number of two people you have know for at least three years. DO NOT use more than one relative as a reference. A mentoring coordinator will be contacting these individuals. We ask that you alert your references in advance.

Personal Reference 1

First Name:

Last Name:

Apartment Number and Street:

City: State: Zip:

Daytime phone: Years known: Relationship:

Personal Reference 2

First Name:

Last Name:

Apartment Number and Street:

City: State: Zip:

Daytime phone: Years known: Relationship:

Volunteer Agreement

I understand that I may be mentoring clients who may have a criminal background and may currently be under supervision by Probation & Parole. I hereby release and discharge PYHIT Altamont Program, Inc. and Peter Young Shelter Services, Inc. and any directors employees, affiliates and clients from any and all liability or responsibility for any accident or injury, which may arise during my participation as a community based mentor. I have not been convicted, within the past ten years, of any felony or misdemeanor classified as an offense against a person or family, of public indecency, or a violation involving a state or federally controlled substance. I am not under current indictment. I understand that the program involves spending a minimum of three hours with my mentee from three to six months. Furthermore, I understand that I will attend an orientation and training session.
I understand that all mentors who come in regular contact with PYHIT community submit to a limited criminal history check. I authorize any person listed above as references on this application to furnish information concerning my personal character, habits, or employment records. I certify that the facts contained in this application are true and complete to the best of my knowledge.

I have read the above Volunteer Agreement and agree to its contents. To the best of my knowledge and belief, all statements in this profile application are true and accurate.
Check button to accept agreement