Online Mentor Application - "I Have A Dream" Foundation

How did you learn about the "I Have a Dream" Foundation - Los Angeles?

Name

First Middle Last

Gender

Date of Birth

Social Security Number

Why are you interested in being a mentor?

Please summarize relevant skills and qualifications you have acquired from employment, volunteer work, or through other activities working with young people.

HOME INFORMATION

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long at this address?

If less than one year, how long at previous address?

Home Phone

Mobile Phone

Best time to reach you?

Email

EMERGENCY CONTACT

Name

First Middle Last

Home Phone

Mobile Phone

Relationship

EMPLOYMENT INFORMATION

Company / Organization

Occupation

Job Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Office Email Address

Office Hours

May we contact you at work?

Best time to call?

How long with current employer?

How long with previous employer?

PERSONAL INFORMATION

Married or Single?

Spouse's Name

First Last

Do You Have Children?

If yes, please list names and ages:

Ethnicity

Driver’s License No. and State

Auto Insurance Co.

Policy No.

Make of Car

Model

Year

Are you fluent in language(s) other than English? If so, please list:

Have you ever been convicted of a crime and/or been investigated for child abuse or neglect?

If yes, please explain and be specific:

EDUCATION

Level of Education:

College/University Major:

Did you have a mentor growing up?

If so, which of his/her qualities helped you grow the most?

MENTORING COMMITMENTS AND LIFESTYLE

Are you confident that you can meet the minimum “I Have a Dream” Foundation-Los Angeles mentoring commitments:

• Commit to one year mentoring a young person in the program
• Visit mentee twice/month during the first three months and once/month thereafter
• Contact mentee once/week by phone, email, text, Facebook, etc.
• Check in with mentee’s Program Coordinator approximately once/month
• Attend a New Mentor Training
• Respect the wishes and guidelines of mentee’s parents/guardians
• Respect confidentiality of mentee and family, barring situations such as child abuse.

What types of activities do you enjoy in your spare time?

Do you belong to any organizations, clubs, religious congregations, or volunteer groups? If yes, please list each group, describe activities, and how often you participate?

During your lifetime so far, have you struggled with any problems that might parallel the difficulties of the children in the program? If yes, please explain.

What characteristics would you most want your mentee to possess? (calm, full of energy, etc.)

What issues in a young person would you prefer not to deal with, such as substance abuse, sexual orientation, ect.? If yes, please explain and be specific.

What is the most important thing you would like your mentee to know about you and your expectations for yourself as a mentor?

How far are you willing to drive to pick up your mentee at his/her home?

Anticipated changes over next 12-18 months and, if so, when?

Employment, residence or personal life (i.e. marriage, divorce)

Affirmation*

First Last

The information I have provided in this application is, to the best of my knowledge, true and complete. I grant permission for the “I Have a Dream” Foundation-Los Angles to verify this information, contact my references, and run a background check that will include contacting the DMV and the Department of Justice. I agree to provide a copy of my driver’s license and auto insurance policy, pay the small background fee, and to participate in a home interview. I understand and agree to the mentoring commitments outlined herein.

Date

PLEASE UPLOAD COPIES OF YOUR DRIVER’S LICENSE AND AUTO INSURANCE POLICY HERE:

A background check will be conducted for each mentoring applicant as required by our insurance company. Please provide the following information: 1) someone who has supervised you either at work, school or as a volunteer; and 2) two personal references who can guarantee your character and morals. We strongly prefer local references who have known you for at least two years. We ask that you please do not list any relatives and that you please provide all of the information requested.

First Last

REFERENCE I (SUPERVISOR/EMPLOYER)

Name

First Last

Title

Company/Organization

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

REFERENCE II (PERSONAL)

Name

First Last

Length and Nature of Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

REFERENCE III (PERSONAL REFERENCE)

Name

First Last

Length and Nature of Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Comments

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