Partnership 4 Kids Mentor Application

Group Mentoring Application
Mentor Basic Information

*Please note, Car insurance info. will be needed to complete this application.

* Legal First Name
Preferred First Name
* Legal Last Name
* Have you ever gone by a different last name?
If Yes, What was it?
* Date of Birth
* Social Security Number
Address
City
State
Zip code
Other cities and states lived in during the last 7 years
Home Phone
Cell phone
Work phone
Work phone ext.
* Email Address
Secondary Email
What is the best way to reach you?
Gender
Ethnicity (optional)
Race
Languages Spoken
If other:
How did you hear about Partnership 4 Kids?
Employer
Occupation
If in the military, do you expect to be deployed within the next 6 months? (optional)
Marital status
Photo Upload
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Other Mentor Questions
What do you hope to gain from the mentoring experience?
What strengths do you bring to the mentoring process?
List other relevant experience (community involvement, hobbies, volunteer work, etc)
Mentor Preferences
Select Your Availability
Emergency Contact Info
Contact name
Contact phone
Contact relationship
References
Reference 1
* First Name
* Last Name
Relationship
How long have you known this person?
Would they be interested in volunteering with you?
Email Address
Phone
Reference 2
* First Name
* Last Name
Relationship
How long have you known this person?
Would they be interested in volunteering with you?
Email Address
Phone
Reference 3
* First Name
* Last Name
Relationship
How long have you known this person?
Would they be interested in volunteering with you?
Email Address
Phone
Proof of Car Insurance
Drivers License #
Issuing State
If you do not have a license, please check this box.
Type
Do you have any impairments that would cause a driving hazard?
Is there anything on your driving or criminal record that we should be aware of before processing your application please explain:

*Please note, Car insurance info. will be needed to complete this application.
* Name of Car Insurance Company
* Insurance Policy Expiration Date
* Policy number
If you do not have insurance, please check this box.
Media Release

I acknowledge receipt of the 'Media Release' and certify that I have read and understand the terms of release. Click here to view the release.

* Media Release Signature
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Media Release Date
Summary of Your Rights Under the FCRA

I acknowledge receipt of the 'Summary of Your Rights Under the FCRA' and certify that I have read and understand these rights. Click here to view the summary.

* FCRA Signature
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FCRA Date
Disclosure Regarding Background Check

I acknowledge receipt of the 'Disclosure Regarding Background Check,' and certify that I have read and understand this document. I hereby authorize Partnership 4 kids to obtain all required screenings and reports. Click here to view the disclosure.

* Disclosure Regarding Background Check Signature
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Disclosure Regarding Background Check Date
* I have submitted the necessary information through the DHHS portal for the abuse registry checks.

Click here to complete the required DHHS screening. The screening must be completed following the instructions provided on the next page to be eligible to volunteer. Once you submit your screening, please check this box indicating that you have submitted the necessary information through the DHHS portal for the abuse registry checks.