Mentor Application

Thank you for applying to be a mentor.

You have come to this site either because of our partnership with KARK 4 News and Fox16 News through the Victory Over Violence campaign or you have been invited by one of our many partners in the community. Your application will be processed and given to our partnering agencies for them to call you and explain their needs and programs to you. We are endeavoring to streamline the application process and your information will be shared with our partnering agencies. Those agencies will contact you so you can interview them about their needs. Once you have chosen an agency, you will be contacted by that agency about having a background check and only that agency will have your personal information. If you have any questions, or no agency has contacted you, please contact Robert H. Holt at 501-516-1602 or email him at r-kholt@att.net

Your First Name (required)

Your Middle Name (required)

Your Last Name (required)

Your Gender (required)

MaleFemale

Your Address (required)

Your City (required)

Your State (required)

Your Zip (required)

Your Home Phone (required)

Your Mobile Phone (required)

Your Name/Address of Employer (required)

Your Work Phone (required)

Your Occupation (required)

Your Email (required)

Do you have any preference in your mentee's education level: (required)
ElementaryJr. High/Middle SchoolHigh SchoolNo Preference

Please check the two statements below:

I understand that the mentor program involves spending a minimum of one hour every week (or 4 hours a month) for the academic year with an assigned student.
I understand that I will be required to complete the mentor program orientation and at least two training sessions during the year.

Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance?

YesNo

Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in the previous question?

YesNo

If the answer is YES to either of the previous two questions, please explain below:

What is your Educational Background (mark one):

Some high schoolGraduate/professional schoolHigh school graduateTechnical schoolSome collegeCollege graduateOther

If you answered "Other" in the previous question, please specify below:

Why do you want to become a mentor?

What days of the week are you available to volunteer? (check all that apply):

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

What is the best time for you to volunteer? (check all that apply):

MorningsAfternoonsEveningsWeekends

Please list four references (please include at least one family member, one personal friend and one work reference) Name, Address, City, State, Zip, Phone Number, Relationship:




In making this application to be a volunteer, I understand that the iBelieve Mentor Program routinely performs criminal and driving record checks of all volunteers for the position of mentor for which I am applying. This check may be done on me if I sign below. If I fail to sign, it may be grounds for rejecting me as a mentor.

I certify to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and on subsequent mentor application forms, is grounds for dismissal.

Please sign:

Background Check Information

Social Security number We will call you for this information(needed for criminal record checks)

Drivers License # and Birth date (needed for record checks)We will call you for this information

Do you prefer working with a particular grade level? (Approximate ages are in parentheses)

K–3 (ages 5–8)Grade 4 (age 9)Grade 5 (age 10)Grade 6 (age 11)

Do you prefer working with a:

BoyGirl

Do you prefer working with a:

Quiet, reserved childOutgoing childNo Preference

Do you prefer working with a student from a specific racial/ethnic group?

YesNoNo Preference

If yes, please specify

If you speak one or more foreign language(s), please specify:

Please list any hobbies or interests you may have:

What would you like to do with a mentee?

What clubs or groups, if any, do you belong to?

My favorite subject in school was:

My least favorite subject in school was:

Please put an X by the activities you enjoy the most:

Playing sportsWatching sportsWritingReadingListening to musicPhotographyAttending playsGoing to the moviesArts and craftsVisiting zoos and parksVisiting museumsUsing computersPlaying gamesCookingExploring possible careersHiking and seeing nature

If you'd like to mention any other hobbies, please specify below:

What qualities would you like in a mentee?

What individual has served as a role model for you? Why?

If you could recommend one book for your mentee to read, what would it be?