Mentor Application

Full Legal Name:
Preferred Name (Nickname):
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone(s)
Alternate Phone
Email

What type of mentoring most interest you? (circle, one-to-one, outdoor programming, projects):
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:
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
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.