Mentor Application

Full Legal Name:

Preferred Name (Nickname):

Pronouns

She, her, hersHe, him, hisThey, theirs

Gender

MaleFemalenon binary

Ethnicity

caucasianAmerican IndianAfrican AmericanLatino/ HispanicNative HawaiianPacific IslanderAsian

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone(s)

Alternate Phone

Email

Education History (schools attended and degrees earned/in-progress):

Please describe your current and previous work history:

Please discuss your previous experience working with youth:

Do you have experience working with or feel comfortable working with LGB TQ+ youth groups?

YesNo

What type of mentoring most interests you?

Circle youth groups1-1 match with youthoutdoor programingCorporate Mentor Partnership support

Do you know of any upcoming change in your life that may impact your involvement with Rogue Valley Mentoring:?

If yes, please explain:

Preferred geographical location for mentoring:

AshlandMedfordTalentPhoenixCentral PointJacksonvilleRuchWhite CityEagle PointShady Cove

Preferred age of youth to mentor:

10 - 1212 - 1414 - 1616 - 1818+CollegeCareer Prep

Do you have any health or physical restrictions that would impact mentoring activities? If so, please explain:

What are some values and beliefs that are important to you?

How do you feel these relate to working with youth in the community?

Are you a licensed driver? Do you have your own transportation?

Name and Policy number for current auto insurance:

Name, relationship, and years known:

Phone

Name, relationship, and years known:

Phone

Name, relationship, and years known:

Phone

Name, relationship, and years known:

Phone

Additional Comments:

Mentor stipend program

The mentor stipend program allows active mentors the opportunity for a $50 monthly stipend.
Before checking the box, please download and read the requirements hereI would like to be considered for the mentor stipend program

Please read before signing:

Yes

By checking 'yes' I agree that all information provided above is correct. I further understand that this application and any information gathered will remain property of Rogue Valley Mentoring. This will act as a digital signature.

New Mentor Application

Education and Experience

Personal Information

References - Please include 2 professional, 1 personal, and 1 familial

Verification