Mentor Application Step 1 of 4 25% Applicant InformationName* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Gender*Pick OneMaleFemaleBirth Date* MM slash DD slash YYYY Home or Cell?*Pick OneHomeCellPhone Number* Emergency Contact InformationName* First Last Phone* How did you find out about Twin Falls Optimist Youth House?*(If you were referred, please mention by whom.)Please tell us why you are interested in being a mentor to former foster youth.*Mentoring a young adult is a big responsibility and can change the lives of both the mentor and the youth. What do you hope to gain from the experience? What do you hope the youth will gain?*Would you agree to have us check your name through the federal and state criminal records of child abuse and neglect proceedings?* Yes No Answering no will disqualify applicant from consideration. List 3 people who can serve as a reference for you.Reference 1 Name* Relationship* Phone*Reference 1 Name* Relationship* Phone*Reference 1 Name* Relationship* Phone*As a volunteer mentor in the Twin Falls Optimist Youth House Mentoring Program, I agree to: Make a one-year commitment to mentoring Attend a training session Notify the program director/case manager if I am unable to keep my mentoring meetings Engage in the relationship with an open mind Accept assistance from program support staff Ask program support staff when I need assistance, do not understand something or am having difficulty with my mentoring relationship Notify the program director/case manager of any changes in my telephone number or contact information Notify the program coordinator of any significant change in my mentee Understand that I am making a long-term, lasting relationship in a young adult’s life when I choose to become a mentorTyped Full Name* Signature* Reset signature Signature locked. Reset to sign again
