Mentor Application

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Mentor Application

Ready to Achieve Mentoring Program

Mentors change futures. Thank you for your interest in becoming a mentor for the Ready to Achieve Mentoring Program.

First Name ^*

Middle Initial ^*

Last Name ^*

Select Your Age Bracket ^*

21+

18-20

17 and under

Date of Birth ^*

Email ^*

Home City ^*

Home Street Address ^*

Home State ^*

Home ZIP ^*

Home Telephone ^*

Employer ^*

Job Title ^*

Supervisor Name ^*

Length of Employment ^*

Work Telephone Number ^*

Have you ever been convicted of a crime? ^*

Yes

If yes, please explain:

Do you object to our agency running a background check on you? ^*

Yes

Why do you want to be a mentor? ^*

Can you meet with youth for 4 hours a month? ^*

Yes

What time can you meet with your mentees? (Circle all that apply) ^*

During Lunch

After School

After 5:00pm

Weekends

Regular Business Hours

Do you have any hobbies, special skills, or career knowledge? ^*

Would you prefer to be matched to youth with a paricular career interest, gender, or other attribute? ^*

Do you have experience working with youth and/or youth with disabilities? ^*

Can you read or speak languages in addition to English? ^*

Professional References

Please list the name, addresses, and phone numbers of three people you would like to use as character references (please list only people you have known for at least a year).

Reference 1 Name ^*

Reference 1 Relationship ^*

Reference 1 Telephone ^*

Reference 1 Email Address

Reference 2 Name ^*

Reference 2 Relationship ^*

Reference 2 Telephone ^*

Reference 2 Email Address

Reference 3 Name ^*

Reference 3 Relationship ^*

Reference 3 Telephone ^*

Reference 3 Email Address

Where did you hear about us?

Please read the Mentor Agreement below. Then, check the box and provide your initials to show you agree. ^*

I Agree

By providing your initials, you agree to the Mentor Agreement. ^*

Please provide the date. ^*

Please read carefully before typing your name below as an electronic signature: Our program appreciates your interest in becoming a mentor to a child. By signing below, you attest to the truthfulness of all information listed on this application. You agree to let our program confirm all information listed and conduct a federal and state criminal records check. I have read and understood the program’s rules, regulations, and responsibilities for becoming a mentor. If selected I will follow the rules of the program and be a dedicated mentor. I agree to the time commitment set forth by the program. ^*

Full Mentor Agreement

CIL Jacksonville

CIL Jacksonville is a charitable, not-for-profit 501(c)3 organization serving the community since 1978.

Monday-Friday
8:00AM-5:00PM
2709 Art Museum Drive
Jacksonville, FL 32207
(904) 399-8484 (voice/TTY)

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