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|  Mail To: Volunteers for Youth 1700 S. Lynn Riggs Blvd., Suite A
Claremore, OK 74017
918-343-2530
Email: palcoordinator@yahoo.com PAL Mentoring Program
Mentor Application
Legal Name____________________________________________________________________________
last first middle
Date of Birth ________________________________ Social Security #_____________________________
Home Address_______________________________City___________________State_______Zip_______
How long at present address?_________years________months
  Home Phone_____________________Work Phone____________________Cell Phone________________
Which number do you prefer to be called at? ____Home ______Work ______Cell
  Marital Status: ____ Single ____ Married ____ Divorced ____ WidowedPlace of Employment___________________________How Long?_____Occupation___________________
Work Address______________________________City___________________State_______Zip_________
If Employed here less than three years, please list previous employers (Attach additional sheets if necessary)
Name of Employer__________________________________________How long there?________________
Street Address_________________________________City_______________State_______Zip_________
Name of Employer__________________________________________How long there?________________
Street Address_________________________________City______________State________Zip_________
Highest level of Education completed: ____ Less than High School ____ High School or GED
____ Vo Tech or College(less than 4 yrs) ____ 4 yr college degree or equivalent ____ Advanced degree
How did you hear about PAL? _____________________________________________________________
Do you have foreign language skills? ____ Yes ____ No If yes, what language? ______________________
Age group with which you would like to be matched: (check all that apply)
____ Elementary _____ Middle School ____ High School
Specific School? ___________________________________________
When are you available to mentor? Day(s)___________________ Time(s)______________________
Volunteers for Youth Use Only
Date Received ________________ Date Matched___________________
Date Background Check Cleared ____________ School _____________________
Date Training Completed __________________ ____ Added to email ____ Added to mailing list
Mentor Application Page 2 Please list three personal references (two must be non-family) who have known you for at least one year. Please be sure to include all information requested.
Name__________________________________________Phone______________________________
Address__________________________________City________________State________Zip_______
Relationship to you_________________________________How long have you known?___________
Name__________________________________________Phone______________________________
Address__________________________________City________________State________Zip_______
Relationship to you_________________________________How long have you known?___________
Name__________________________________________Phone______________________________
Address__________________________________City________________State________Zip_______
Relationship to you_________________________________How long have you known?___________
Your addresses over the last three years, prior to your current address: ____ If same, check here. Street________________________________________Apt#_________City____________State_____
Street________________________________________Apt#_________City____________State_____
(attach additional sheets if necessary)
Have you ever been convicted of, plead guilty or nolo contendere (neither admitting nor denying the charge) to, or received a suspended imposition of sentence, been placed on probation, or otherwise found guilty of:
Any criminal or municipal ordinance violation? ____ Yes ____ No DUI/DWI ____ Yes ____ No   Have there ever been allegations, complaints or reports regarding your involvement in child abuse or neglect? (regardless of whether the incident was confirmed or denied) ____ Yes ____ No
If yes to any of the above, please provide date, description and explanation of each incident on additional paper.
You have my permission to contact the references listed above. I understand that any omissions or misstatements made by me on this application form may be cause for my application to be declined or volunteer status to be terminated. I consent to Volunteers for Youth to verify any information I have provided. I declare that all statements I have made on this application are true, correct and complete to the best of my knowledge. I understand that Volunteers for Youth, at their sole and complete discretion, may accept or decline this application without providing me any reasons for the decision.
_____________________________________________________ _______________________
Signature Date
12/09
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