Mentor Application Continued | Become a Man Without a Man

Please list all the members of your household.*

Employment History 1*

Employment History 2*

Employment History 3*

Why do you want to become a mentor?*

Do you have any previous experience volunteering or working with youth? If so, please specify.*

What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain.*

Can you commit to participate in Become a Man Without a Man, Inc. mentoring program for a minimum of one year from the time you are matched with a youth?*

Yes

No

Are you available to meet with a child eight - twelve hours per month and have contact at least once per week? Please explain any scheduling issues.

Yes

No

Describe your general health. Are you currently under a physician’s care or taking any medications? If so, please explain.

How would you describe yourself as a person?*

How would your friends, family, and co-workers describe you?*

Have you ever been arrested or convicted of a crime? *

Yes

No

If so, what were the circumstances?

Have you ever used illegal drugs?*

Yes

No

If so, what substances were used and how often?

Are you currently using any illegal drugs or controlled substances?*

Yes

No

Do you drink alcoholic beverages?*

Yes

No

If so, what and how often?

Have you ever been convicted of a DUI, driving while under the influence of alcohol?*

Yes

No

If yes, when and what were the circumstances?

Do you use tobacco products?*

Yes

No

If so, what and how often?

Have you ever received treatment for alcohol or substance abuse?*

Yes

No

If yes, please explain.

Have you ever been treated or hospitalized for a mental disorder?*

Yes

No

If yes, please explain.

Have you ever been investigated or convicted of child abuse or neglect?

Yes

No

If yes, please explain.

Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger?*

Yes

No

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 difficulties during your participation in the mentoring program?*

Are you willing to attend an initial mentor training session and two in- service training sessions per year after being matched?*

Yes

No

I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.*

Yes

No

I understand that Become a Man Without a Man, Inc. is not obligated to provide a reason for its decision to accept or reject me as a mentor.*

Yes

No

I agree to allow Become a Man Without a Man, Inc., 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.*

Yes

No

By typing my name below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.*

Application to Mentor Continued