Mentor Application Mentor Application Thanks so much for your interest in becoming a Mentor. Please fill out the below form and we will get in touch with you promptly regarding next steps. If you prefer to fill out a paper application, please click here. Name Email How long have you lived on Orcas?? Mailing Address Home Phone Cell Phone Driver's License (State and Number) Date of Birth Do you have car insurance? Yes No Do you have reliable transportation? Yes No Do you have a clean driving record? Yes No Please provide information for 2 personal references, other than relatives: Reference 1 Reference 2 Why do you want to be a mentor? What do you feel you have to offer a young person? Tell us about your employment experiences: Tell us about your volunteer experiences: Do you agree to make a one year commitment to this program? Yes No Can you commit to spending at least one hour a week with your mentee? Yes No Do you agree to attend an orientation training that will prepare you to be a mentor? Yes No Do you agree to communicate regularly and share activity updates with the Mentor Coordinator? Yes No Do you agree to attend occasional mentor meetings or required trainings? Yes No Have you ever been accused, arrested, charged or convicted of child abuse, exploitation or molestation? Yes No Have you ever been convicted of any crime, or is there any pending criminal charges against you? Yes No Are you currently using any illicit drugs? Yes No Do you use alcohol or controlled substances in an excessive manner? Yes No Are you currently in treatment for substance abuse? If a substance abuse problem has occured in the past, you must have completed a non-addictive period of at least 5 years) Yes No Are you currently under treatment for a mental disorder, or have you been hospitalized for a mental disorder in the past 3 years? Yes No If you wish to provide further details or information about questions in this section, please do so here: Are you willing to submit to a state and federal background check? Yes No I hereby authorize The Funhouse to use this form to conduct a criminal history check through both the Washington State Patrol Identification/Criminal History Section and the Federal Bureau of Investigation. I certify that all information in the application is true and correct. Yes No Please electronically sign by typing your full name: Today's Date Send
