Angel’s Helping Hands Nonprofit Organization Mentorship Program incorporates several essential elements designed to promote safe, effective, and high-quality mentoring relationships. As part of our commitment to excellence and youth safety, Angel’s Helping Hands conducts thorough screening of all prospective mentors, a critical component of any successful mentoring program.

This careful screening process helps ensure that selected mentors are well-qualified, trustworthy, and aligned with our mission, while safeguarding the well-being of the youth we serve. In addition, these measures help manage organizational risk and liability, allowing us to maintain a secure and supportive mentoring environment.

We are committed to protecting your privacy. All personal information collected during the screening process is handled with the highest level of care and will be kept strictly confidential in accordance with our privacy and data protection standards.

Personal Information

Date:

Name:

Street Address:

City: State: Zip:

Cell phone:

Work phone:

Email:

Last 4 of Social Security Number:

Date of Birth ___/___/___ Gender:  Male  Female

Current Driver’s License No.: State:

Ethnicity: ____African American ____Hispanic ____White ____Asian ____Other (please specify) ______________

Emergency Contact Name: Phone Number: Relationship:

Employment History

Please provide employment information for the past five years, with most recent position held

first.

1st

Employer:

Street Address:

City: State: Zip:

Supervisor’s Name: Title:

Phone:

Dates of Employment: to (month/year)

Position Held:

2nd

Employer:

Street Address:

City: State: Zip:

Supervisor’s Name: Title:

Phone:

Dates of Employment: to (month/year)

Position Held:

3rd

Employer:

Street Address:

City: State: Zip:

Supervisor’s Name: Title:

Phone:

Dates of Employment: to (month/year)

Position Held:

Personal References

Please list three people you would like to use as character references. Any information Angel’s Helping Hands Mentorship Program gathers from these references will be held confidential and will not be released to you, the applicant.

Name:

Phone:

Email:

Relationship:

How long known:

Name:

Phone:

Email:

Relationship:

How long known:

Name:

Phone:

Email:

Relationship:

How long known:

Please answer all the following questions as completely and truthfully as possible.

1. Why do you want to become a Mentor?

2. Do you have any previous experience Mentoring or working with youth? If so, please

specify.

3. What qualities, skills, or other attributes do you feel you have that would benefit a mentee?

Please explain.

4. Can you commit to participate in the Mentorship Program for a minimum of nine (9) months and dedicate 4-6 hours a month to the program if you are accepted as a mentor?

5. Describe your general health. Are you currently under a physician’s care or taking any medications? If so, please explain.

6. How would you describe yourself as a person?

7. How would your friends, family, and co-workers describe you?

8. Have you ever been arrested or convicted of a crime? If so, what were the circumstances?

9. Have you ever used illegal drugs? If so, what substances were used and how often?

10. Are you currently using any illegal drugs or controlled substances?

11. Do you drink alcoholic beverages? If so, how often?

12. Have you ever been convicted of a DUI, drinking while under the influence of alcohol? If

yes, when and what were the circumstances?

13. Do you use tobacco products? If so, how often?

14. Have you ever received treatment for alcohol or substance abuse? If yes, please explain.

15. Have you ever been treated or hospitalized for a mental disorder? If yes, please explain.

16. Have you ever been investigated or convicted of child abuse or neglect? If yes, please explain.

17. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? If yes, please explain.

18. Are you willing to communicate regularly and openly with program staff and receive feedback regarding your participation in the Mentoring program?

19. Are you willing to attend an Mentor training sessions per program cycle?

20. Did you participate in Angel’s Helping Hands last program cycle as a mentor? If so, how was your experience?

Contact and Information Release

I, _________________________________________, understand it will be necessary for Angel’s Helping Hands Mentorship Program to conduct a background check regarding my criminal history, personal references, and employment.

I authorize Angel’s Helping Hands to obtain any needed information regarding my legal/criminal history, character references, and employment from any state or federal agency, my employer, and personal references for the purpose of participating in a Mentoring program.

Further, I provide permission for Angel’s Helping Hands to conduct the same investigation of my background in previous states in which I have resided.

Further, I understand that information about me will be anonymously (without my name) shared

with a prospective mentee(s) and her parent(s)/guardian(s) to aid in determining a suitable

match. Once a Mentor/Mentee match is determined, my identity and any other information

known about me may be shared with the Mentee and parent/guardian to ensure and aid in

facilitating a safe and successful match relationship.

Signature

Date

Please read this carefully before signing:

Angel’s Helping Hands Mentorship Program appreciates your interest in becoming a Mentor.

Please initial each of the following:

_______ I agree to follow all Mentoring program guidelines and understand that any violation will result in suspension and/or termination.

_______ I understand that Angel’s Helping Hands Mentorship Program is not obligated to provide a reason for their decision in accepting or rejecting me as a Mentor.

_______ (optional) I agree to allow Angel’s Helping Hands Mentorship Program to use any photographic image of me taken while participating in the Mentoring program. These images may be used in promotions or other related marketing materials.

I understand I must complete all the following items along with this application, and that any incomplete information will result in the delay of my application being processed:

 Copy of your valid driver’s license

 Resume

 Complete Criminal Background & Sex Offender Check

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Signature

Date