Mentor Application

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone

(###)

###

####

Work Phone

(###)

###

####

Date of Birth

YYYY

Martial Status

Number of Children

Occupation

Employer

Place of Worship

1. What are your hobbies and interests?

2. Describe the special knowledge or skill, which you could contribute to the group on the trail, to an individual student, or to the program in general:

3. Describe your experience with hiking, climbing, wood lore, or other adventure activities:

4. What experience have you had relating to adolescents?

5. What personality traits do you possess which would help you work with youth who may have emotional and/or behavioral problems?

6. What limitations do you have in scheduling one week of summer vacation time for the New Hampshire trip:

7. Do you think your employer may be open to giving you paid time off to participate in this portion of the program? Would you like us to ask on your behalf?

8. What limitations do you have in attending monthly group activities, usually the 2nd Saturday of each month, 9 am to 1 pm?

9. If you are selected as a mentor, are you able and willing to commit to weekly phone or personal contacts with your student, and meeting with him/her once a month for one-on-one time?

10. Do you have a current and valid driver’s license?

11. Is providing transportation for yourself and your student to and from activities a problem?

12. Describe your philosophy of helping delinquent or at-risk youth.

13. Have you ever been convicted of any crime, including sex-related or child abuse related offenses?

Reference 1

To assure that the youth in this program have the most suitable role models, please submit the names of three individuals we may contact for a letter of reference. Please make sure addresses are complete and accurate.

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone

(###)

###

####

Reference 2

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone

(###)

###

####

Reference 3

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone

(###)

###

####