Mentor Mom Application

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female

Marital Status*
Spouse's Name
First Last
Race/Ethnicity*
- American Indian
- Asian
- Black or African American
- Caucasian
- Native Hawaiian or Other Pacific Islander
Driver's License #*
Highest Education You've Achieved:*
Day Time Phone*
Evening Time Phone*
Cell Phone*

Professional Information
Occupation*
Employer*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Phone*
Email*
Fax

Religious Information
Place of Worship Name:*
Religious Leaders Name:*
Place of Worship Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Place of Worship Phone:
Mentoring Information
Are you willing to spend at least two years investing in the life of a child with weekly contact?*
- Yes
- No
Do you have previous experience with mentoring?*
- Yes
- No
If so, how many years?*
You do not need to be a biologically mother to be paired with a young mother.

How and when did you come to faith in Christ?*
Please list the reasons why you want to be a youth mentor:*
Explain any experience you have had in working with children:
If you are married or living with relatives, how does your family feel about you becoming a mentor?
Please list interests and hobbies:*
Have you ever been charged with or been convicted of a criminal offense, other than a traffic violation?*
- Yes
- No
If yes, please explain:*
Signature:*
First Last
Today's Date:*
MM slash DD slash YYYY

Background Verification Authorization
I hereby authorize Blueprint 58 to request and receive any and all background information about or concerning me, including but not limited to my Criminal History, Social Security Number Trace including a consumer report under the Fair Credit Reporting Act, 15 U.S.C 1681, Driving Record, Employment History, Military Background, Civil Listings, Educational Background, Professional License from any Individual, Corporation, Partnership, Law Enforcement Agency, and other entities including my Present and Past Employers

The criminal history, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by client/agency and a procedure is available for clarification, if I dispute the record as received. I also understand that the criminal history could contain information presumed to be expunged.

I further release and discharge Blueprint 58 and all of their Subsidiaries, Affiliates, Officers, Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request for information or records pursuant to this authorization, procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable.

I understand that I have the right to make written request within a reasonable period of time for additional information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided the above information for employment/volunteer purposes, and I have carefully read and understand this authorization.

By signing below I accept the role of helping my mentee develop his/her God given gifts and to bring the Gospel to his/her attention and I will make the minimum contacts each month as outlined in the training.
Signature:*
First Last
Today's Date:*
MM slash DD slash YYYY

Reference Information #1
Reference #1 Name*
First Last
Reference #1 Phone*
Reference #1 Email*
Reference Information #2
Reference #2 Name*
First Last
Reference #2 Phone*
Reference #2 Email*
Reference Information #3
Reference #3 Name*
First Last
Reference #3 Phone*
Reference #3 Email*

Thank you for filling out the online portion of the mentor application. Once you click submit below you'll be sent an email with additional documentation that we'll need for you to fill out. Thanks again!

Step 1 of 8

Professional Information

Religious Information

Mentoring Information

Background Verification Authorization

Reference Information #1

Reference Information #2

Reference Information #3