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Mentor Application


Mentor Information
This question requires a valid date format of MM/DD/YYYY.
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 NameRelationshipDate of Birth
Household member 1
Household member 2
Household member 3
Household member 4
Household member 5
Emergency Contact Information
Can you converse in Spanish?
Do you have any allergies?
Do you carry an EpiPen?
Have you ever been charged with or convicted of a felony? 
Have you ever been charged with or convicted of a misdemeanor?  
Have you been cited for a traffic violation within the last two years?
Do you attend church?
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.
Signature of
Reference 1
Reference 2
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.
Signature of