Goodwill SCIA | Mentor Application

Date*
Legal Name
Last*
First*
Middle
Home Address
Address*
Street AddressAddress Line 2CityStateZIP Code
Telephone
Daytime*
Evening
Cell
Email*
Alternate Email
Birth Date
Gender
- Male
- Female
Current Driver’s License Number (OPTIONAL)
State
GoodGuides Youth Mentoring Program Staff may request proof of auto insurance and copy of driver’s license at the time of enrollment.

Application Questions
Explain why you want to become a mentor.
Do you have any previous experience volunteering or working with youth? (Specify)
What do you feel are the strengths you can bring to this program?
Within the past five years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, an offense of public indecency, or a violation involving a state/federally controlled substance?
- Yes
- No
If yes, please explain:

Personal and Professional References

Please list three references
(Please include at least one family member and one work reference)
Reference #1
Name
Relation
Address
Street AddressAddress Line 2CityStateZIP Code
Daytime Phone
Evening Phone
Cell Phone
Reference #2
Name
Relation
Address
Street AddressAddress Line 2CityStateZIP Code
Daytime Phone
Evening Phone
Cell Phone
Reference #3
Name
Relation
Address
Street AddressAddress Line 2CityStateZIP Code
Daytime Phone
Evening Phone
Cell Phone

Certification and Authorization

If you agree to become a mentor, you will be asked to agree to the basic requirements listed below.
(Please check each statement to indicate you agree)
*
- I understand that the GoodGuidesSM youth mentoring program involves spending a minimum of four hours per month for one year from the time I’m matched with a youth participant.
- I understand that I will be required to complete six hours total for orientation and training, along with two in-service training sessions per year after being matched with a mentee.
- I understand and authorize GoodGuides youth mentoring program to obtain any needed information regarding my driving record, legal/criminal history, character references, and employment from any state or federal agency, my employer, and personal references for the purposes of participating in The GoodGuides Mentoring Program. I provide permission for GoodGuides to conduct the same investigation of my background in previous states in which I have resided.
- I understand that information about me, after approved into the GoodGuides youth mentoring program, will be anonymously (without my name) shared with a prospective mentee(s) and his/her parent(s)/guardian(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and any other information known about me may be shared with the mentee and parent/guardian to ensure and aid in facilitating a safe and successful match relationship.
Please list any other cities, states, and dates of residency during the past 10 years.
City
State
Dates
City
State
Dates
City
State
Dates
Confidentially Acknowledgement

If you agree to become a mentor, you will be asked to adhere to the follow confidentially statement.
(Please check the statement to indicate you agree)
*
- I acknowledge that during my volunteer service as a mentor through the GoodGuidesSM youth mentoring program I will come in contact with propriety and confidential information regarding the GoodGuides youth mentoring program, and information pertaining to the youth that I am mentoring. I agree that I will not share or divulge any confidential and/or proprietary information regarding the GoodGuides youth mentoring program or the youth or families involved in the program while I am active in the GoodGuides youth mentoring program and after I leave the program. I also understand there is no expiration date and therefore all confidential information will not be divulged regardless of my status in then GoodGuides youth mentoring program.
An applicant between 16 and 17 will require a parent or guardians signature.
Name
This field is for validation purposes and should be left unchanged.

Services

Mentor Application

Youth Mentoring Program
Mentor Application

Step 1 of 6

Legal Name

Home Address

Telephone

Do you have the following accounts? (Fill out all that apply)

Employer Information

Alternate/Emergency Contact Information

Legal Name

Home Address

Telephone

Mentor's Personal Interests

What do you like to do in your free time? Select all that apply and specify further details in the space provided.

Application Questions

Personal and Professional References

Please list three references

Reference #1

Reference #2

Reference #3

Certification and Authorization

If you agree to become a mentor, you will be asked to agree to the basic requirements listed below.

Please list any other cities, states, and dates of residency during the past 10 years.

Confidentially Acknowledgement

If you agree to become a mentor, you will be asked to adhere to the follow confidentially statement.

Services

Mentor Application

Youth Mentoring Program Mentor Application

Step 1 of 6

Legal Name

Home Address

Telephone

Do you have the following accounts? (Fill out all that apply)

Employer Information

Alternate/Emergency Contact Information

Legal Name

Home Address

Telephone

Mentor's Personal Interests

What do you like to do in your free time? Select all that apply and specify further details in the space provided.

Application Questions

Personal and Professional References

Please list three references

Reference #1

Reference #2

Reference #3

Certification and Authorization

If you agree to become a mentor, you will be asked to agree to the basic requirements listed below.

Please list any other cities, states, and dates of residency during the past 10 years.

Confidentially Acknowledgement

If you agree to become a mentor, you will be asked to adhere to the follow confidentially statement.

Youth Mentoring Program
Mentor Application