Mentor Application

Welcome!
Our Vision: Transform communities by matching safe, nurturing adult mentors with area youth so they reach their full potential and become positive societal contributors. I appreciate your interest in sharing our vision.
The application will take an average of 30 minutes. The application MUST be completed in one session.
You will need your driver's license number, car insurance information, and license plate number. All information collected on this application is confidential. If you need help or additional support, please don't hesitate to email the Program Coordinator at sara@kinshipcc.org.

Thank you!
Sara McChesney, MSW
Program Coordinator

Contact Information

First Name *This question is required.

Last Name *This question is required.

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

calendar

Gender *This question is required.

If other, please specify. *This question is required.

Street Address *This question is required.

Apt/Suite

City *This question is required.

Zip *This question is required.

Please list any other addresses that you have had during the past 10 years. *This question is required.

Email Address *This question is required. This question requires a valid email address.

Primary Phone Number *This question is required. Please provide a 10-digit phone number including area code.
Enter numbers only. Formatting such as dashes will be added as you enter your phone number.

Secondary Phone Number

Spouse/Partner name: *This question is required.

Number of years together *This question is required.

Do you have children? *This question is required.

Children

Number of Children

Please list name, age, and gender of each child

Which children are currently living at home? *This question is required.

Who else lives in the home? All adults 18 and older residing in the home must complete a background check. *This question is required.

Are you currently employed? *This question is required.

Employment Information

Current Employer

Your Position

Work Street Address

Apt/Suite/Office

City

Zip

May we contact you at work?

Work Phone Number *This question is required.

Length of time at this job

Have you ever served in the military? *This question is required.

Military Service

Time served

Branch

Date and kind of discharge

List service clubs and organizations you belong to or have volunteered for *This question is required.

Are you affiliated with a church or religious institution? *This question is required.

Name of church/ religious institution *This question is required.

List your past experiences with youth *This question is required.

How would you describe your present health? *This question is required.

Poor	Fair	Good	Excellent
Poor	Fair	Good	Excellent

Any mental, medical, or physical conditions that may impact your mentoring relationship with a child? *This question is required.

If yes, explain: *This question is required.

Have you ever been diagnosed with or received treatment for any of the following? (include dates and other relevant information)

Mental Health Challenges

Substance Use Challenges

Survivor of abuse

Do you have a valid driver’s license? *This question is required.

Driver's License Information *This question is required.

State

Driver's License Number

If not, do you have a driver or other means of transportation? (describe) *This question is required.

Do you have your own car? *This question is required.

If no, do you have regular access to a car? *This question is required.

License Plate Number *This question is required.

Do you have current insurance? *This question is required.

Insurance Information *This question is required.

Name of Insurance Company

Policy #

Have you had any moving violations or accidents in the last 5 years? *This question is required.

Please describe *This question is required.

If you said other, please specify.

Do you anticipate any major life changes within the next year? *This question is required.

If yes, explain *This question is required.

Have you ever been arrested? *This question is required.

If yes, please explain (offense, date, location, circumstance, and outcome): *This question is required.

How did you learn about the Kinship Program? *This question is required.

If you said other, please specify. *This question is required.

Mentor Application

Demographics