Mentor Application

Mentor Information

First Name

Last Name

Street Address

Apt/Suite

City

State

Zip

Email Address

Phone Number

Work Number

Mobile Phone

Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

Current Employer

Job Title

Ethnicity

African American
Asian/Pacific Islander
Caucasian (Not of Hispanic descent)
Hispanic/Latino
Other - Write In Please enter an 'other' value for this selection.

Number of Children This question requires a valid number format.

Can you commit for at least 1 calendar year (2 years preferred)?

Please list the other individuals (including minors) that are part of your household and their ages (adults over 18 may be subject to a background check).

Space Cell	Name	Relationship	Date of Birth
Household member 1	Household member 1: Name	Household member 1: Relationship	Household member 1: Date of Birth
Household member 2	Household member 2: Name	Household member 2: Relationship	Household member 2: Date of Birth
Household member 3	Household member 3: Name	Household member 3: Relationship	Household member 3: Date of Birth
Household member 4	Household member 4: Name	Household member 4: Relationship	Household member 4: Date of Birth
Household member 5	Household member 5: Name	Household member 5: Relationship	Household member 5: Date of Birth

Emergency Contact Information

Full Name

Relationship

Home Phone Number

Work Phone Number

Mobile Phone Number

How did you learn about SpringSpirit?

Do you have any volunteer experience? If so, please list where and give a brief description of that volunteer experience?

Can you converse in Spanish?

Do you have any allergies?

What are you allergic to?

Do you carry an EpiPen?

Have you ever been charged with or convicted of a felony?

If yes, please explain

Have you ever been charged with or convicted of a misdemeanor?

If yes, please explain

Have you been cited for a traffic violation within the last two years?

If yes, please explain

Please explain why you would like to mentor a child from SpringSpirit.

Do you attend church?

If so, where do you typically attend?

Tell us a bit about your spiritual journey or what God has done in your life.

I certify that I am currently maintaining Motor Vehicle Liability Insurance and carry a minimum of $100,000 per person, $300,000 per accident and $100,000 property damage or $300,000 combined single limit. In the event that such insurance is terminated or canceled for any reason, I agree to promptly notify SpringSpirit. I also agree not to operate a vehicle in connection with my child I am matched with until my insurance is reinstated.

I agree that my insurance will be the sole and primary insurance coverage in the event of an accident while transporting my SpringSpirit mentee. I agree to operate the vehicle in as safe and legal manner as possible while transporting my SpringSpirit mentee.

Clear

Signature of

Reference 1

Full Name

Relationship

Phone Number

Email Address

Reference 2

Full Name

Relationship

Phone Number

Email Address

By signing below, I certify that all information given on this application is true and complete to the best of my knowledge. I know that by completing this application I am not automatically accepted as a mentor for a child. I also agree to the following guidelines:

1.   I will hold confidential all information that I obtain directly or indirectly concerning children and their families.
2.   My time is donated as a volunteer mentor to a child who is a member of SpringSpirit.
3.   I will make my best effort to be on time, be conscientious, conduct myself professionally, and be courteous and considerate of others at all times.
4.   I will not hold SpringSpirit responsible for any accidents or injuries that may occur while I am with my child.

Clear

Signature of

Mentor Application

Welcome