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Mentors Counte Alliance Mentor Application

Complete this application to be considered for the Mentors Counte Alliance mentorship program. All information is kept confidential and used solely for volunteer screening.

Personal Information:

Full Name *

Date of birth *

Address *

City / State / ZIP *

Phone *

Email *

Driver’s License Number & State *

Employment & Background

Current Occupation *

Employer *

How long with current employer? *

Mentorship Interest

Why do you want to join Mentors Counte Alliance? *

Have you ever mentored youth before? If yes, please describe. *

Background & Legal Disclosure

Answer each question. A “Yes” response does not automatically disqualify you. Failure to disclose will.

Have you ever been convicted of a felony? *

Yes

Have you ever been convicted of a misdemeanor involving a child, violence, drugs, or sexual misconduct? *

Yes

Have you ever been investigated, accused, or disciplined for inappropriate conduct involving minors? *

Yes

Are you currently under investigation for any criminal charges? *

Yes

If you answered “Yes” to any question above, please explain:

References (3 non‑family, known you 3+ years)

Reference 1 – Name / Relationship / Phone / Email *

Reference 2 – Name / Relationship / Phone / Email *

Reference 3 – Name / Relationship / Phone / Email *

Authorization & Consent

I certify that the information provided is true and complete. I authorize Men‑Tours to obtain and review background checks, including but not limited to criminal records, sex‑offender registry, and reference/employment verification. I understand that false statements or omissions may result in denial or termination of volunteer service. I agree to comply with all Men‑Tours policies and child‑safety guidelines.

Type Full Name as Signature *

Date *

I agree to the Authorization & Consent above

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