Mentor Application

Full Legal Name*

First Last

Preferred Name (Nickname)

Pronouns*

She, her, hers
He, him, his
They, them, theirs

Gender*

Male
Female
Non-binary

Ethnicity*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Alternate Phone*

Education and Experience

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

Personal Information

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

Yes
No

What type of mentoring most interests you?

Circle Youth Groups
1-1 Match with Youth
Outdoor Programming
Corporate Mentor Partnership support

If you have any upcoming changes in your life that may impact your involvement with Rogue Valley Mentoring, please explain

Preferred geographical location for mentoring

Preferred age of youth to mentor

10 - 12
12 - 14
14 - 16
16 - 18
18+
College
Career Prep

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

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

I am a licensed driver

Yes
No

I have my own transportation

Yes
No

Name, carrier, and policy number for current auto insurance

References

Please include 2 professional, 1 personal, and 1 familial

1) Name, relationship, years known, phone

2) Name, relationship, years known, phone

3) Name, relationship, years known, phone

4) Name, relationship, years known, phone

Agreements and Signature

Additional Comments

Mentor stipend program

The mentor stipend program allows active mentors the opportunity for a $50 monthly stipend.

I would like to be considered for the mentor stipend program

Agreement*

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

Yes

Signature*

Please sign the form, using your finger on a touch device, or mouse on computer

Name

This field is for validation purposes and should be left unchanged.