Couple/Family Mentor Application

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

Please provide the following information, to submit the form online.


Couple/Family Mentor Application Part I

Please fill-in all applicable fields.


Applicant #1 Section



Applicant #2 Section


Please fill-in all applicable fields.

Household Members Information


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

I am interested in applying for the: (Check all that apply)

Please include; Name, Offense, Date (one offense per line)
List; Name, Offense, Date (one offense per line)

Request for Driving Check

Please complete and return the attached Request for Driving check.
SCHOOL-BASED MENTORS ONLY: DISREGARD INSURANCE QUESTIONS

Car Insurance
Mentors/Volunteers are required to have automobile insurance and must carry auto liability limits with a minimum of $300,000 combined single limit or split limits of $100,000/$300,000.

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.

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.

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.

Use full legal name, please.
Use full legal name, please.

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