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
D.O.B.:
Enter Here
Physical Address:
Enter Here
City:
Enter Here
Enter Here
Email Address:
Enter Here
Home phone:
Work phone:
Communication
Preference :
Enter Here
State:
Enter Here
Enter Here
Mailing Address (if different):
City:
Last Name:
State:
Enter Here
Enter Here
Cell Phone:
Enter Here
Enter Here
Contact you at work?
Choose Here
Email
Phone Call
Text
Mail
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
1
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
College/ Location:
Enter Here
Major Field of Study:
Enter Here
Graduate?
Years:
#Here
Degree?
Choose
Choose
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.
2
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: [email protected]
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
3