Mentoring Application

Our Mentoring Program is a mutually beneficial experience that pairs youth ages 6-12 years old in need of additional adult presence in their lives with a trusted adult mentor from the local community. Mentor matches are encouraged to spend a minimum of four hours a month together participating in activities that can help expand each person’s worldview including volunteering, trying new foods, making crafts, participating in fun activities, attending local events, and more. Our Mentoring Program also brings all matches and youth on the waitlist together once per month for planned social and creative activities.

After filling out the form you will be contacted by Cathy Pierson, Director of Volunteer and External Relationships, in the near future.

Contact Information

Name *

First Name

Last Name

Birthday *

(mm/dd/yyyy)

Email *

Verify Email *

Cell Phone Number *

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

How long have you resided in the area? *

Employer *

Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Can we contact you during work hours? If so, what is the best time?

What is your highest level of education? *

Elementary

Middle School

High School

2 Year College

4 Year College

Graduate School and Above

If you attended college, what degree did you obtain?

Family Status *

Mentors received background checks and home visits. For the mentee's safety, it is required that we know the members of your household

Single & Live Alone

Single & Live with Roommates/Children

In A Relationship but Live Alone

In a Relationship & Live with Partner/Children

Married

Separated/Divorced

Widowed

If married, how many years have you been married?

If you have children, how many children and what are their ages?

Are you affiliated with any service, occupational, or fraternal groups? If so, please list them.

How did you learn about The LeaderShop? *

Why do you want to become a Mentor? *

Do you have any past experience working with children & youth? If so, please describe. *

Have you ever applied to be a mentor in a one-on-one Youth Program? *

Yes

Have you ever been a volunteer in a one-on-one Youth Program? *

Yes

Have you discussed the possibility of becoming a Mentor with your family? *

Yes

At this time, do you feel you will be able to remain in the program for at least one year? *

Yes

Do you sincerely feel you can meet the minimum standard of spending at least 4 hours per month with an assigned child? *

Yes

What age child would you prefer to be matched with? *

What are your special interests? What interests do you have that might appeal to a child/youth? *

How can you, as a Mentor, help a child? *

Are there any activities you dislike or cannot do? *