1
Mentor Application
Please attach a picture to the application
Personal Information
Name: ______Date: ______
Street Address: ______Neighborhood (Shchuna)______
City: ______Zip:______Email: ______
Home Phone: ______Work Phone: ______Cell Phone:______
Teudat Zehut #:______Maiden Name ______
If you are not a citizen what is your legal status? ______
Date of Birth___/___/____ Male Female
How did you come to apply for this position?______
Which languages do you speak?______
Please list all members of your household:
Name / M/F / AGE / RELATIONSHIP TO APPLICANTMENTORING PROGRAM
Employment Experience
Please provide employment information for the past five years. With most recent
position held first. If more space is needed use an extra sheet of paper. Please include
current phone numbers and indicate whether the employer may be contacted as a reference.
Employer: ______
Street Address: ______
City: ______State:______Zip: ______
Supervisor's Name: ______Title: ______
Phone: ______
Dates of Employment: ______to______(m/year)
Position Held: ______
I give permission to contact my employer yes no
------
Employer: ______
Street Address: ______
City: ______State:______Zip: ______
Supervisor's Name: ______Title: ______
Phone: ______
Dates of Employment: ______to______(m/year)
Position Held: ______
I give permission to contact my employer yes no
------
Employer: ______
Street Address: ______
City: ______State:______Zip: ______
Supervisor's Name: ______Title: ______
Phone: ______
Dates of Employment: ______to______(m/year)
Position Held: ______
I give permission to contact my employer yes no
KAV L'NOAR
MENTORING PROGRAM
Education: Yeshiva/ Post High School Experience
Yeshiva/School: ______
Street Address:______
City: ______State:______Zip:______
Rosh Yeshiva's/ Director's Name: ______
Phone: ______
Dates of Attendance: ______to ______(month/year)
I give permission to contact my Rosh Yeshiva/Director yes no
------
Application Questions
Please answer all of the following questions as completely as possible. If more space is needed, use an extra sheet of paper, or write on the back of this page.
- 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?
- Can you commit to participate in the Kav L’Noar mentoring program for a minimum of one year from the time you are matched with a youth?
5a. Are you available to meet with a child 8 hours per month and have contact 1-2 times
per week? Please explain any scheduling issues.
5b. Are you available to meet with a supervisor 1 hour a month? And 5-6 times per year in the evening for group supervision?
KAV L'NOAR
MENTORING PROGRAM
6. Describe your general health? Are you currently under a physician's care or taking
any medications? If so, please explain.
7. How would you describe yourself as a person?
8. How would your friends, family, and co-workers describe you?
9. Are you willing to communicate regularly and openly with program staff, provide
monthly information regarding your mentoring activities, and receive feedback
regarding any difficulties during your participation in the mentoring program?
Personal References
Please list the names, addresses, and phone numbers of three people you would like to use as character references ( only people you have known for at least a year) Any information the Kav L'Noar Mentoring program gathers from these references will be held as confidential and not released to you, the applicant.
Name ______
Address ______
City______State______Zip______
Phone______
Relationship______How long known______
------
Name ______
Address ______
City______State______Zip______
Phone______
Relationship______How long known______
Name ______
Address ______
City______State______Zip______
Phone______
Relationship______How long known______
What are the most convenient times for you to meet with your mentee? Please check all that apply.
After School: ______Evenings:______Nights:______
Please indicate age group(s) and/or you are interested in working with:
Age: ___10-12 ___13-15 ____16-18_____
What are some favorite things you like to do with other people?
What are your favorite subjects to read about?
What is your job and how did you choose this field?
What is one goal you have set for the future?
If you could learn something new, what would it be?
What person do you most admire and why?
Describe your ideal shabbos.
Check the activities you enjoy:
Biking / Camping / Science/Electronics / Cooking / LibraryHiking / Boating / Music / Sports / Musical Instruments
Art / Swimming / Gardening / Parks / Movies
Crafts/Carpentry / Animals / Eating / Board Games / Shopping