Mentor Application

Basic Information
First Name / Middle Name / Last Name
Street Address / Apartment/Unit
City / State / Zip
Cell Phone / Home Phone / Work Phone
Email / What is the best way to reach you?
Gender / Birthdate / Employer
Emergency Contact Name / Relationship to you / Phone
How did you hear about us? Please be as specific as possible.
Application Questions
Why do you want to become a mentor with Simpson Housing Services?
How did you hear about us? Please be as specific as possible.
Do you have any previous experience volunteering or working with youth? If so, please describe (including name of organization, time of involvement, type of work).
Have you ever been refused participation in any other youth program? Yes ☐No☐
If yes, please explain.
What qualities, skills, training, or other attributes do you feel you have that would benefit a youth? Please explain.
Have you had any experience working with people in poverty or people experiencing homelessness? Please describe experience if applicable.
Please describe your experience working with people from a variety of cultural backgrounds.
Share your educational background, training, language skills, etc.
What language(s) are you proficient in?
What is your occupation (current or previous)?
Can you commit to the Simpson Mentoring Program for one year, being in contact with your mentee weekly and seeing them a minimum of 40 weeks out of the year? Yes ☐No☐
Do you foresee any issues meeting this requirement (ex. planned extended vacations, possible relocation, unreliable transportation, etc)?
Do you have any medical or health-related concerns which could affect your ability to perform those activities expected of you as a coach or ensure the safety of the student in your care, especially in the event of an emergency? If so, please explain.
Have you had any driving citations and/or moving violations in the past 5 years? If yes, please explain.
Have you ever been convicted of a crime? Yes ☐No☐
If yes, please disclose all convictions in the last 10 years, including the year and state of conviction. Having a conviction doesn’t necessarily exclude you from volunteering.
Have you ever been investigated or convicted of child abuse or neglect, or of sexually abusing a youth 18 years or younger? If yes, please explain.
References
Please list three persons, not related to you, who would have knowledge of your qualifications to volunteer.
Full Name / Relationship to you
Phone / Email
Full Name / Relationship to you
Phone / Email
Full Name / Relationship to you
Phone / Email
Anything else you’d like us to know:
Application Agreement
By submitting your application, you agree to the following:
ü  I certify that my answers are true and complete and I understand that if they are not, I am disqualifying myself for a volunteer position.
ü  I also understand that I am applying for a volunteer position and that this is not an application for, or a contract of, employment.
ü  I understand that this application does not guarantee a placement, and that either Simpson or myself can terminate the process of applying at any point without an explanation.
ü  I authorize the above references to give Simpson Housing Services any pertinent information they may have and authorize investigation of all statements contained in this application.
Signature / Date

Return to: Simpson Housing Services

Attention: Charlotte Kinzley

2100 Pillsbury Avenue South

Minneapolis, MN 55404

Or fax to 612.879.0041