First Name Last Name Address City State Zip Phone
Check one LandlineCell Email Date of Birth
Gender:MaleFemaleTransgender
Name Phone Relationship to you
Your Occupation Your Employer Work Number Start Date End date or still working
Will you agree to allow Father Matters to check your background through federal and state agencies for criminal records and child abuse and neglect proceedings? YesNo
Do you have a valid Driver’s License or ID YesNo
State Issue
Date Issued
Expiration Date
ID Number
Have you ever been convicted of a crime? YesNo
Have you ever been investigated or convicted of child abuse or neglect?: YesNo
Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger?: YesNo
If “Yes”, please explain
Why do you want to be a mentor?
Do you have any previous experience volunteering or mentoring?
Do you have any hobbies or special skills?
What support or resources would you need to be successful as a mentor?
Have you ever been matched with a mentor? YesNo
What was successful and challenging about being mentored?
Can you commit to participate in the Father Matters Reentry Mentoring program for at least 3 months from the time you are matched? YesNo
How would you describe yourself as a person?
How would your friends, family, and co-workers describe you?
Have you ever used illegal drugs? YesNo
If so, what substances were used and how often?
Do you drink alcoholic beverages? YesNo
Have you ever been convicted of a DUI, driving while under the influence of alcohol? YesNo
Have you ever received treatment for alcohol or substance abuse? YesNo
Have you ever been treated or hospitalized for a mental disorder? YesNo
Have you ever been investigated or convicted of child abuse or neglect? YesNo
Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? YesNo
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? YesNo
Are you willing to attend an initial mentor training session? YesNo
Please complete all the following. This survey will help the Father Matters Adult Reentry Mentoring program know more about you and your interests and help us find a good match for you.
What are the most convenient times for you to meet or talk with your mentee? Please check all that apply.
Weekdays:DaytimeEvenings
Weekends:DaytimeEvenings
Are you comfortable with talking with your mentee through these options? Cell PhoneGoogle DuoZoomMessengerFace Time
Please indicate age group(s) you are interested in working with: 16-1718-2425–4041–older
Please indicate what Ethnicity you are interested in working with:
Do you speak any languages other than English? If so, which languages?
Would you be willing to work with a participant who has disabilities? YesNo
What are some favorite things you like to do with other people?
What are your favorite subjects to read about?
What is one goal you have set for the future?
If you could learn something new, what would it be?
Please check all activities you are interested in: BikingCampingScienceCookingLibraryHikingBoatingMusicSportsYogaGolfSwimmingGardeningParksMoviesFishingAnimals/PetsPainting/PhotosBoard GamesShopping
List any other areas of strong interest:
Father Matters appreciates your interest in becoming a mentor. Please review and check all the statements to agree to the terms of participating in the mentoring program.
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
I agree to speak to the evaluation team from LeCroy & Milligan once a month as needed to discuss how you feel about volunteering as a mentor. I AGREE
I understand that the Father Matters Adult Reentry Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor. I UNDERSTAND
(optional) I agree to allow Father Matters Adult Reentry 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 AGREE
I understand I must email over a copy of my Driver's License by email to info@fathermatters.org after submitting this application. I UNDERSTAND
Copy of my valid driver’s license. YES
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? I AGREE
Are you willing to attend an initial mentor training session? I AGREE
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:
Todays Date:
