Children's Mentoring Connection of Hancock County

Mentor/Volunteer Application Part I

Please complete all applicable fields.

Name (include middle initial, maiden name or AKA):

Date of Birth

Gender

Address

City, State

Zip

Home Phone

Cell Phone

How long at Current Address

How long have you lived in Hancock County?

Email Address

Place of Employment

Occupation

Working Hours

How long have you worked here?

Work Phone

May we call you at Work?

Yes No

EDUCATION: (Years Completed)

High School Trade College Other

Marital Status

Spouse's Name

Spouse Place of Employment

What Is Your Spouse’s and/or Family’s Reaction to the Possibility of You Becoming an Agency Volunteer?

Please List Household Members

List; Name, Age, Relationship (one person per line)

Children living outside of the home

List; Name, Age, Relationship (one person per line)

Driver's License Number

State Issued

Expiration Date

Do you have the required limits on your insurance policy?

Yes No

Name of Insurance Company

Policy Number

Your Agent's Name

Agent's Phone Number

REFERENCES:

Please list the names, addresses and phone numbers of three people who can vouch for your reputation, character and morals and who have known you for at least one year. If employed, please include present employer, regardless of length of employment. If you do not work, use another personal reference. Do not use relatives. We will be making phone contact with your references, so please provide us, if possible, with a daytime and evening phone number.

1. Name (Supervisor)

Work Phone

Home/Cell Phone

Business Address

City, State, Zip

Company Name

E-mail

2. Name

Work Phone

Home/Cell Phone

Business Address

City, State, Zip

3. Name

Work Phone

Home/Cell Phone 3

Business Address

City, State, Zip

I hereby authorize Children’s Mentoring Connection of Hancock County to make such investigation as it deems proper and necessary regarding my background and to determine the accuracy of the information I have furnished in this qualification record. Furthermore, I hereby release any Agency or organization from liability for cooperating with CMC of Hancock County by releasing the requested information.

Authorize Do not Authorize

Children’s Mentoring Connection of Hancock County reserves the right to deny a volunteer application when, in its sole discretion, it believes it is in the best interest of CMC to do so and is not obligated to match you with a child.

Applicant Signature

Full Name, Please

Date of Application

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Mentor/Volunteer Application

If you prefer you may download and fill-in the Printable Application Form

Mentor/Volunteer Application Part I

REFERENCES:

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