Impact Youth Mentorship

Impact Youth Mentorship

IMPACT Youth Mentorship

Date: Click here to enter a date.
Which volunteer opportunity do you wish to pursue? / Choose Option Here
How did you hear about the IMP ACT Youth Mentorship Program? / Click here to enter text.

Mentor Application

Personal Information

First Name: / Enter Here / Last Name: / Enter Here
D.O.B.: / Enter Here
Physical Address: / Enter Here
City: / Enter Here / State: / Enter Here
Mailing Address (if different): / Enter Here
City: / Enter Here / State: / Enter Here
Email Address: / Enter Here
Home phone: / Enter Here / Cell Phone: / Enter Here
Work phone: / Enter Here / Contact you at work? / Choose Here
Communication Preference : /
Gender: / Choose / Ethnicity: / Choose Option
Driver’s License Number: / Enter Here / State: / Enter Here
Occupation: / Enter Here / Employer: / Enter Here
Religion: / Enter Here / Marital Status: / Choose
Spouse’s/Partner’s Name: / Enter Here / Age: / Enter Here
Spouse’s Occupation: / Enter Here / # years in relationship: / Enter Here

Others living in the Home:

Name: / Enter Here / DOB / DOB / Relationship: / Enter Here
Name: / Enter Here / DOB / DOB / Relationship: / Enter Here
Name: / Enter Here / DOB / DOB / Relationship: / Enter Here

Education

High School/Location: / Enter Here / Graduate? / Choose
College/ Location: / Enter Here / Years: / #Here / Degree? / Choose
Major Field of Study: / Enter Here

Pre-application Questions

Do you sincerely feel that you can meet the minimum requirement of meeting with your mentee once a week?
Choose Here
Do you feel that you will be able to remain in the program for at least one (Calendar or academic) year? Choose Here
Do you object to the agency checking with appropriate public authorities (for example: police, courts, Department of Motor Vehicle, Child Abuse and Registry etc.) For matters of public record regarding your background?
Choose Here
Has your driver’s license ever been suspended or released? Choose Here
Have you ever been arrested? Choose Here
If yes please explain: Click here to enter text.
Have you ever been investigated for adult or child abuse, neglect or endangerment? Choose Here
Have you ever volunteered before: Choose Here
If yes please explain: Click here to enter text.
Do you have any physical or emotional conditions which may limit your ability to serve as a mentor? Choose Here
If yes please explain: Click here to enter text.
List your experience working with children: Click here to enter text.
What behaviors or characteristics in a child would make you uncomfortable in a matched situation?
Click here to enter text.

References
Please give information for your references (preferably people you have known for more than 1 year and who are not related to you):

Personal # 1 / Enter Here / Phone # / Enter Here / Email / Enter Here
Personal #2 / Enter Here / Phone # / Enter Here / Email / Enter Here
Professional #1 / Enter Here / Phone # / Enter Here / Email / Enter Here
Professional #2 / Enter Here / Phone # / Enter Here / Email / Enter Here

Please Email application to:

Please Contact Dawn Dillinger for any question!

Office: 307-686-0669 ext 1701

YES House- (IMPACT Youth Mentorship Program) – 905 N Gurley Ave, Gillette, WY 82716

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