LifeWorksMentoring.org

Mentor Application for LifeWorks Mentoring

Please take the time to answer each question, all are required.

Personal Information

Name:
	(Last)	(First)	(MI)

Address:
	(Address)	(City)	(State)	(Zip)

Home Phone:

Cell Phone:

E-Mail Address:

Date of Birth:

Gender:

Marital Status:

Languages Spoken:

Employment

Employer:

Occupation:

Business Phone:

May we contact you at work? Yes No

Matching
This information is optional but may help us to make the most appropriate match.

Race/Ethnicity:

Age:

Sexual Orientation:

Gender Identity:

Highest Education Level Completed:

Referred by:

Other interests that will be helpful for LifeWorks Staff to know about:

Please provide us with three references.

1. Personal Reference such as relation or friend:

Name:

Phone:

Address:

2. Personal Reference such as relation or friend:

Name:

Phone:

Address:

3. Professional/Business Reference:

Name:

Phone:

Address:

Mentoring Questions

The following information is required:

1. What is Mentoring to you?

2. What is your experience regarding Lesbian, Gay, Bisexual and Transgender (LGBT) youth?

3. What can you offer a young person as a Mentor?

4. Explain what “boundaries” mean to you?

5. Describe any volunteer work that you have done?

6. What do you think are three of the biggest issues facing Lesbian, Gay, Bisexual and Transgender (LGBT) youth?

7. What are some of the most important attributes that a mentor should possess?

8. Do you have any medical or mental health requirements that would need to be accommodated?

9. Why do want to be a mentor and what do you hope to gain from the experience?

10. What are the best times for you to attend the Mentor training and Support groups?

This information is intended to provide preliminary information. Additional information will be obtained by Lifeworks Mentoring. By clicking the "Submit Information" button below, I hereby certify that I am 21 years of age or older and I grant permission to Lifeworks Mentoring to conduct a complete character background check including a Criminal Records, Department of Justice Child Abuse Index registry and Department of Motor Vehicles inquiry.

After your application is received we will contact you to schedule an interview. If you have further questions about the Mentoring Program please contact Dinorah Garcia, Client Consultant at dgarcia@lifeworksmentoring.org

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