Apply to be a Journeymen Mentor

Personal Information

First Name

Last Name

Email

Phone

Driver's License

Upload Image

Proof of Auto Insurance

Upload Image

Address

Address Line 1

Address Line 2

City

State

Zip Code

My mailing address is different

Yes

No

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Please list any other organizations you are currently involved with

References and Legal Record

Please list 4 persons who have known you for at least a year. For example:

Your current or past employer
A co-worker or friend
Your significant other or someone with whom you reside. If you live alone, someone familiar with your home environment.
Someone who has observed you interacting with children.

First Name

Last Name

City

Relationship

Email

Phone

Years Known

First Name

Last Name

City

Relationship

Email

Phone

Years Known

First Name

Last Name

City

Relationship

Email

Phone

Years Known

First Name

Last Name

City

Relationship

Email

Phone

Years Known

Application Questions

Please answer all the following questions as completely as possible.

Why do you want to become a mentor?

Do you have any previous experience volunteering or working with youth? If so, please specify.

What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain.

Can you commit to participate in the Journeymen Mentoring Program for a minimum of one year?

Are you available to meet with a boy in Journeymen’s JGroups or outings for four hours per month? Please explain any scheduling issues.

Describe your general health. Are you currently under a physician’s care or taking any medications? If so, please explain.

How would you describe yourself as a person?

How would your friends, family, and co-workers describe you?

Have you ever been arrested or convicted of a crime?

Yes

No

What were the circumstances?

Are you currently using any illegal drugs or controlled substances?

Yes

No

Please explain.

Do you drink alcoholic beverages?

Yes

No

How often?

Have you ever been convicted of a DUI, driving while under the influence of alcohol?

Yes

No

When and what were the circumstances?

Do you use tobacco products?

Yes

No

How Often

Have you ever received treatment for alcohol or substance abuse?

Yes

No

Please explain.

Have you ever been hospitalized for a mental disorder?

Yes

No

Have you ever been hospitalized for a mental disorder?

Yes

No

Please explain.

Have you ever been investigated or convicted of child abuse or neglect?

Yes

No

Please explain.

Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger?

Yes

No

Please explain.

Are you willing to communicate regularly and openly with program staff, provide monthly in- formation regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program?

Yes

No

Release of Liability

Please read this carefully and check each of the following:

I acknowledge that I have received, and agree to follow all mentoring program Guidelines, Policies and Procedures, and understand that any violation will result in suspension and/or termination of involvement with Journeymen.

I understand that the Journeymen Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.

I acknowledge that I may be transported by a mentor and/or Journeymen staff or representatives while participating in the Journeymen program, and that such transportation is voluntary and at my own risk.

I release the Journeymen Mentoring Program of all liability of injury, illness, death, or other damages to me, my family, estate, heirs, or assigns that may result from my participation in the program and hold harmless any Journeymen mentor, program staff, or other representatives, both collectively and individually, of any injury or illness, physical or emotional.

I certify that the information provided in the application questions is a complete and accurate statement of the physical and psychological factors that may affect my involvement in Journeymen. I agree to notify Journeymen should there be any changes in my health status. I authorize Journeymen to release this information to medical personnel in an emergency. I understand that Journeymen reserves the right to refuse participation to anyone, at their discretion, for medical reasons.

(Optional) I agree to allow the Journeymen 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.

I understand I must return a copy of my valid driver’s license and proof of current auto insurance coverage along with this application, and that any incomplete information may result in the delay of my application being processed.

By agreeing here, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Signature

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Apply to be a Journeymen Mentor

Personal Information

References and Legal Record

Application Questions

Release of Liability

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