Mentor Application
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Personal Information
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| Name
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| Prefix
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| First
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| Last
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| Suffix
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| Criminal Background Check
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| By checking this box I understand the Central Records Division of the Michigan State Police (Lansing, Michigan) requires some of the information asked in this application. I authorize the Lakeshore Ethnic Diversity Alliance to utilize the information To ensure the safety of our clients, staff, and other volunteers, a mandatory background check will be performed. As a prospective volunteer for the Lakeshore Ethnic Diversity Alliance, it is this agency’s policy to secure criminal history information as part of the pre-volunteer screening process using the information you have provided on this application.
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| Names Previously Used (Including Birth Name)
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| Date of Birth
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| Are you over 18 yrs old?
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| Yes Mentors must be over 18 years old when they begin mentoring.
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| Gender
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| Female Male
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| Race/Ethnicity
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| Home Address
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| Street Address
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| Address Line 2
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| City
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| State / Province / Region
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| Postal / Zip Code
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| Country
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| Email Address
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| Phone Number (Work)
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| Phone Number (Home)
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| Phone Number (Cell)
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| Do you have any affiliations that you would be willing to let us know about? (Employer, School, Faith Community, etc)
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| Do you have any specific skills that you would like to let us know about?
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| Why do you want to mentor a child?
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| What experience do you have working with children?
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| Do you speak Spanish?
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| Yes Somewhat No This is not required to volunteer for the Migrant Mentoring Program.
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| Might you be open to mentoring two children together? (such as siblings, cousins, close friends)
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| Yes Maybe No
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| What age of child(ren) do you prefer to work with?
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| What interest and activities would you share with a child?
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| Have you ever been involved in child abuse or other inappropriate behavior with a child? If yes, please explain.
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| Have you ever been arrested or received any citations other than for minor traffic violations? If yes, please explain.
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| Have you experienced any major changes in your life in the past year If yes, please explain.
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| Do you anticipate any major change in your life in the coming year? If yes, please explain.
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| Availability
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| Weekdays afterschool Weekday evenings Weekends The Migrant Mentoring Program requires that mentors be available to meet with the children after school or on weekends. This is true even through the summer months since children go to Migrant Summer School. Please check your availability above.
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| Do you have reliable transportation?
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| Yes Sometimes No
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Relationships
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| Relationship Status
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| Married Single Divorced Seperated Dating Committed Relationship
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| (If applicable) Will your significant other be joining you in mentoring activities?
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| Yes Sometimes No Depending on involvement and circumstances, we may need to run a background check on him/her. If you select yes, please provide the information needed below.
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| Signficant Other's Name
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| Prefix
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| First
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| Last
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| Significant Other's Previously Used Names
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| Significant Other's Birthdate
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| Significant Other's Gender
| Female Male
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| Significant Other's Race/Ethnicity
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| Do you have any children? If so, please list their names and ages.
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Employment
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| Most Recent Employer
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| Position/Occupation
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| Employment Term
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| Full-Time Part-Time Self Employed Retired
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| How long have you held this position?
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References
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| Reference One (Name, Relationship to You, Phone Number or Email Address)
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| Reference Two (Name, Relationship to You, Phone Number or Email Address)
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| Reference Three (Name, Relationship to You, Phone Number or Email Address)
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| Reference Four (Name, Relationship to You, Phone Number or Email Address)
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How'd You Heard About the Program?
Help us to know what marketing efforts are working by selecting the options below that lead you to applying for this program.
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| Checkbox
| Diversity Alliance e-newsletter or website Newspaper article An announcement, flier or in the bulletin at my faith community Referral from a friend or co-worker Speaking presentation at my church or school Other organization or school newsletter (please indentify below) Volunteer Match Volunteer Solutions Facebook Other (please identify below)
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| Other
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