Mentor Volunteer Application

Name First, Middle, Last:

_________________________________________________________

Gender:_____ Race: _____ DOB: _____ Driver's License No.: _____ SSN: ___ __ ____

Street Address:

___________________________________________________________

City State Zip:

___________________________________________________________

Mailing Address:

____________________________________________________________

Contact Number (s):

Home: ___________________

Work: ____________________

Cellular: __________________

Pager: ___________________

Email Address(s) (Please print legibly): ________________________________________

Have you ever worked as a volunteer __No ___Yes

If yes, which agency and dates._____________________________________________

_______________________________________________________________________

Please give reason why you are no longer participating with that agency:

________________________________________________________________________

________________________________________________________________________

The reason(s) I would like to volunteer with A Better Way, Inc. as a mentor is:

________________________________________________________________________

________________________________________________________________________

Is there a particular age, gender, or language group you would like to work with?

___No ___ Yes Please list preference (s):___________________________________

______________________________________________________________________

Is there a particular age group you feel less comfortable working with? ___ No ___Yes. If yes,

please list age(s) _______________________________________________

Are there any special interests that you have which you would like to share with a men tee?

___No ___ Yes. Please list _______________________________________

_____________________________________________________________________

Medical History:

Do you have any medical conditions that would preclude you from volunteering? (hypertension,

asthma, etc.): __________________________________________________________

______________________________________________________________________

Date of your last tuberculosis test (month/year):_ _____________________________

**for use of SLED, NCIC, Child Registry, Driving Record and Sex Offender Background checks.

(Please attach a copy of your resume, and 3 professional references.):

________________________________________________________________________

Signature of Member with date:

________________________________________________________________________

Signature of A Better Way Staff with date:

________________________________________________________________________