Mentor Application There was an error trying to submit your form. Please try again.Personal Information Full Name * This field is required. Date * mm/dd/yyyy This field is required. Street Address * This field is required. Line 2 This field is required. City * This field is required. State * This field is required. Postal Code * This field is required. Country * Select an optionAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of the CongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic of Persian GulfIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic of KoreaKorea, Republic of South KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States of MicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaReunionSaint BarthelemySaint Helena, Ascension and Tristan Da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic of TanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic of VenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaYemenZambiaZimbabwe This field is required. Home Phone * This field is required. Work Phone This field is required. Social Security Number * Your social security number (SSN). This field is required. Date of Birth * Must be 21+ years old mm/dd/yyyy This field is required. Age * This field is required. Gender * Select an optionMaleFemale This field is required. Ethnicity * White Hispanic African American Asian Other This field is required. If other selected This field is required. Household Members * List up to 5 household members. This field is required.Employment HistoryPlease provide employment information for the past 5 years, with most recent position held first.Employer 1 Employer * This field is required. Position Held * This field is required. Street Address * This field is required. Line 2 This field is required. City * This field is required. State * This field is required. Postal Code * This field is required. Country * Select an optionAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of the CongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic of Persian GulfIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic of KoreaKorea, Republic of South KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States of MicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaReunionSaint BarthelemySaint Helena, Ascension and Tristan Da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic of TanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic of VenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaYemenZambiaZimbabwe This field is required. Date of Employment * [Month/Year] to Month/Year] This field is required. Manager Name * This field is required. Phone Number * This field is required.Employer 2 Employer This field is required. Position Held This field is required. Street Address This field is required. Line 2 This field is required. City This field is required. State This field is required. Postal Code This field is required. Country Select an optionAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of the CongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic of Persian GulfIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic of KoreaKorea, Republic of South KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States of MicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaReunionSaint BarthelemySaint Helena, Ascension and Tristan Da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic of TanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic of VenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaYemenZambiaZimbabwe Date of Employment [Month/Year] to Month/Year] This field is required. Manager Name This field is required. Phone Number This field is required.Employer 3 Employer This field is required. Position Held This field is required. Street Address This field is required. Line 2 This field is required. City This field is required. State This field is required. Postal Code This field is required. Country Select an optionAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of the CongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic of Persian GulfIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic of KoreaKorea, Republic of South KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States of MicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaReunionSaint BarthelemySaint Helena, Ascension and Tristan Da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic of TanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic of VenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaYemenZambiaZimbabwe Date of Employment [Month/Year] to Month/Year] This field is required. Manager Name This field is required. Phone Number This field is required.Application QuestionsPlease answer all of the following questions as completely as possible. 1. Why do you want to be a mentor? * This field is required. 2. Do you have any previous experience volunteering or working with youth? If so, please specify. * This field is required. 2. Do you have any previous experience volunteering or working with youth? * Yes No This field is required. If yes, please specify. This field is required. 3. What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain. * This field is required. 4. Can you commit to participate in the Marc’d For Greatness Foundation Youth Mentoring Program for a minimum of one year from the time you are matched with a youth? * Yes No This field is required. Please explain any particular scheduling issues. This field is required. 5. Are you available to meet with a child eight hours per month and have contact at least once per week? * Yes No This field is required. 6. Are you currently under a physician's care or taking any medications? * Yes No This field is required. If so, please explain and describe your general health. This field is required. 7. How would you describe yourself as a person? * This field is required. 8. How would your friends, family, and co-workers describe you? * This field is required. 9. Have you ever been arrested or convicted of a crime? * Yes No This field is required. If so, what were the circumstances? This field is required. 10. Have you ever used illegal drugs? * Yes No This field is required. If so, what substances were used and how often? This field is required. 11. Are you currently using any illegal drugs or controlled substances? * Yes No This field is required. If so, what and how often? This field is required. 12. Do you drink alcoholic beverages? If so, what and how often? * Yes No This field is required. If so, what and how often? This field is required. 13. Have you ever been convicted of a DUI, driving while under the influence of alcohol? * Yes No This field is required. If yes, when and what were the circumstances? This field is required. 14. Do you use tobacco products? * Yes No This field is required. If so, what and how often? This field is required. 15. Have you ever received treatment for alcohol or substance abuse? * Yes No This field is required. If yes, please explain. This field is required. 16. Have you ever been treated or hospitalized for a mental disorder? * Yes No This field is required. If yes, please explain. This field is required. 17. Have you ever been investigated or convicted of child abuse or neglect? * Yes No This field is required. If yes, please explain. This field is required. 18. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? * Yes No This field is required. If yes, please explain. This field is required. Are you willing to communicate regularly and openly with program staff, provide monthly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program? * Yes No This field is required. Are you willing to attend an initial mentor training session and two inservice training sessions per year after being matched? * Yes No This field is required.Please check the following: I agree to follow all mentor program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship. * This field is required. I understand that the Marc’d For Greatness Foundation Youth Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor. * This field is required. I agree to allow the Marc’d For Greatness Foundation Youth Mentoring Program to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials. (Optional) I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed: * This field is required.Copy of your valid driver’s license and proof of auto insuranceInformation Release FormPersonal References FormInterest Survey formDMV Release Form (state agency form)Criminal History Release Form (state agency form)Child Abuse and Neglect Release Form (state agency form)Sexual Offender Release Form (state agency form)By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions. Signature * This field is required. Date * mm/dd/yyyy This field is required. Submit There was an error trying to submit your form. Please try again.
