MENTORS, INC. Volunteer Application 1012 14th Street, NW Suite 304 Washington, DC 20005 Phone - (202) 783-2310 Fax (202) 783-2315 Contact Information Please type or print clearly (Last) (First) (Middle Initial) Name * (Street) (Apt#) Home Address* (City) (State) (County) (Zip) Phone Number* (Home) (Mobile) Personal e-mail address: (to be used for weekly updates) Date of Birth*: Social Security*: Sex: F M Race/ethnicity: Language(s) spoken other than English: *Some information is necessary for conducting a criminal background check Employment Profession: Job title: Employer: (Street) Employer Address: (City) (State) (Zip) Phone number: (Work) (Fax) Work e-mail address: Would you like us to keep your employer abreast of your volunteer service and achievement? Yes No
Education High School: (Graduation date: month/year) (GED: date) University/College: (Major) (Dates attended) (Degree) Graduate School: (Field) (Dates attended) (Degree) Trade School: (Field) (Dates attended) (Degree) Military Service: (Branch) (Rank) (Dates of service) Additional Skills/Community Involvement Hobbies, favorite recreational activities: Please check all that apply Attending Plays Basketball Computers/Video Games Cooking/Eating Out Dancing Drawing/Painting Football Listening to music Movies Museums Music (general) Playing music Reading Shopping Sports (general) Tennis Working out Writing Other (please specify)
Please list any groups, clubs or organizational memberships: General Information Please describe your volunteer experience (include organization names, and dates of service) What experiences have you had that may prepare you to work as a volunteer in the field of youth development? Why do you want to volunteer with Mentors, Inc. and what do you want to gain from this volunteer experience? Have you ever been convicted of a crime? [If yes, please explain the nature of the crime and the date of the conviction and disposition.] Conviction of a crime is not an automatic disqualification for volunteer work. If yes, please explain: Do you have a driver s license? Yes No Do you have car Insurance? Yes No Car available for transporting others? Yes No Indicate your availability: AM (8-12) PM (1-5) Mondays Tuesdays Wednesdays Fridays Saturdays Total Weekly Hours AM PM AM PM AM PM AM PM AM PM Other:
References *Please list two references one (1) from a significant other or close relative; and one (1) from an employer or colleague (Name/Organization) (Relationship to you) (Phone number) 1. (Phone number) (Name/Organization) 2. *See next page for additional information needed (Relationship to you) Please read the following carefully before signing this application: I understand that this is an application for and not a commitment or promise of volunteer opportunity. I certify that I have and will provide information throughout the selection process, including on this application for a volunteer position and in interviews with Mentors, Inc. that is true, correct and complete to the best of my knowledge. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would unfavorably affect my application for a volunteer position. I understand that information contained on my application will be verified by Mentors, Inc. I understand that misrepresentations or omissions may be cause for my immediate rejection as an applicant for a volunteer position with Mentors Inc. or my termination as a volunteer. Background Check I understand that by signing this application I hereby authorize Mentors, Inc. to conduct a criminal background and motor vehicle record check for the safety and well being of all program participants. I further authorize without reservation, any personnel or other entity contacted by Mentors, Inc. and/or its agents, to furnish the above-mentioned information. Photo Release I understand that by signing this application I hereby consent to the use of my name, likeness and speech in any audiotape, videotape, film, photograph, or electronic transmission or display made during the course of the Mentors, Inc. program for any business purpose. I certify that the above responses are true to the best of my knowledge. Signature Date
Additional application requirements: 1. Background Check Have your fingerprints taken by an official FBI Channeler (www.fieldprint.com is one such service) and email the PDF to fkhaldun@mentorsinc.org or bring the paper result to our office. Volunteers cover the costs of FBI background checks. 2. Letters of Reference Submit two (2) reference forms: one (1) from significant other or close relative and one (1) from an employer or colleague. The forms should be sent within 15 calendar days of your application date. The mailing address is: Mentors, Inc., 1012 14 th Street, NW, Suite 304, Washington, DC 20005, Attn: Reference. FOR OFFICE USE ONLY Date Application Rec d & initials Entered in Dbase Training Date Revised July 2015