Be Proactive

* - Required field

Basic Info

First Name

Middle Name

Last Name

Prefix

Suffix

Salutation

Contact Information

Home Phone

Work Phone

Work Phone Extension

Cell Phone

Fax

Pager Number

May contact at work

Email Address

Alternate Email Address

Website

Preferred Method of Contact

Username

Password

Demographic

Date of Birth

Gender

Ethnicity

Home Address

Home Address 1

Home Address 2

Home City

Home Phone

Home State

Home Zip Code

Family Members

	Name	Sex	Age	Relationship
1.
2.
3.
4.

Business Adress

Business Name

Business Address 1

Business Address 2

Business City

Business State

Business Zip Code

Application Questions

1. Why do you want to become a mentor?

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

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

4. Can you commit to participate in the Be Proactive mentoring program for a minimum of one year from the time you are matched with a youth?

5. Are you available to meet with a child in order to meet monthly program requirements? Please explain any particular scheduling issues.

6. Do you suffer from any medical conditions that could prevent you from meeting your responsibilities as a mentor? If so, please explain.

7. How would you describe yourself as a person?

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

10. Have you ever used illegal drugs? If so, what substances were used and how often?

11. Are you currently using any illegal drugs or controlled substances?

12. Do you use tobacco products? If so, what and how often?

13. Do you drink alcoholic beverages? If so, what and how often?

9. Have you ever been arrested or convicted of a crime? If so, when did it occur and what were the circumstances?

14. Have you ever been convicted of a DUI, driving while under the influence of alcohol? If yes, when and what were the circumstances?

15. Have you ever received treatment for alcohol or substance abuse? If yes, please explain.

16. Have you ever been treated or hospitalized for a mental disorder? If yes, please explain.

17. Have you ever been investigated or convicted of child abuse or neglect? If yes, please explain.

18. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? If yes, please explain.

19. 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?

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

Please indicate age group(s) you are interested in working with:

Do you speak any languages other than English? If so, which languages?

Are you willing to mentor more than one student?

Are you willing to work with a child with disabilities?

What are some favorite things you like to do with other people?

What are your favorite subjects to learn about?

What is your job and how did you choose this 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 and why?

Describe your ideal Saturday.

If you could learn something new, what would it be?

Please indicate your interests

References

1

Reference 1 First Name

Reference 1 Last Name

Reference 1 City

Reference 1 State

Reference 1 Zip

Reference 1 Phone

Reference 1 Relationship

2

Reference 2 FIrst Name

Reference 2 Last Name

Reference 2 Relationship

Reference 2 City

Reference 2 State

Reference 2 Zip

Reference 2 Phone

3

Reference 3 Last Name

Reference 3 Relationship

Reference 3 City

Reference 3 State

Reference 3 First Name

Reference 3 Zip

Reference 3 Phone

4

Reference 4 First Name

Reference 4 Last Name

Reference 4 Relationship

Reference 4 City

Reference 4 State

Reference 4 Zip

Reference 4 Phone

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