Street Adress * City * State * Zip Code * Preferred Phone * Alternate Phone * Date of Birth * Age * How did you learn about Cheryl Scott Ministries? * Why do you want to become a mentor? * What do you hope to get out of the mentoring experience? * Do you have any previous experience volunteering or mentoring? If so, please describe.* * What industry or field is your specialty? * The Cheryl Scott Mentoring Program requires dedication, commitment, professionalism, availability and accountability. Are you willing to accept the following program requirements? Please check each requirement you as a mentor for Cheryl Scott Ministries agree to. * Please explain any particular issues that would challenge your ability to keep the above commitments. * How would you describe yourself using 5 words? * Have you ever been arrested or convicted of a crime? Have you received treatment for alcohol or substance abuse? Have you been diagnosed or hospitalized with a mental illness? If yes, to any of these questions please explain. * Eductional History.....Please list the schools you have attended and the degrees/certifications you have completed. * Please list any other cities, states, and dates of residency during the past 10 years. * Reference 1: (Name, Street Address, City /State / Zip Code, Email, Phone, Relationship, Years Known) * Reference 2: (Name, Street Address, City /State / Zip Code, Email, Phone, Relationship, Years Known) * Reference 3: (Name, Street Address, City /State / Zip Code, Email, Phone, Relationship, Years Known) * Employment History: Please provide employment information from the past 5 years starting with your current position. If you have never worked enter n/a in the section below. Current Employment (Employer, Job title , Street Adress, City/State/Zip code, Supervisors Name, phone Number, Dates of Employemt, Primary Responsibilities) Employer 2: (Employer, Job title , Street Adress, City/State/Zip code, Supervisors Name, phone Number, Dates of Employemt, Primary Responsibilities) Employer 3: (Employer, Job title , Street Adress, City/State/Zip code, Supervisors Name, phone Number, Dates of Employemt, Primary Responsibilities) Mentor Application Agreements and Information Release: Please read this carefully before signing: I understand that information about me will be anonymously (without my name) shared with a prospective mentee to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and any other information about me may be shared with the mentee to ensure and aid in facilitating a safe and successful match relationship. I attest that I have no driving record convictions such as Driving Under the Influence (DUI), reckless driving, or excessive speed violations. I attest I do not have a felony record. I give consent to have a background check performed and I understand failure to comply will disqualify my application.
By signing Above (Full Name) , I attest to the truthfulness of all information listed on this application, I authorize Cheryl Scott Ministries to verify the information and I agree to all the above terms and conditions.