Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1698833030013.pdf (Saint Kitts and Nevis)
Mentor Application PERSONAL INFORMATION Name: ______________________________________________________ Date: _________________________ Address: _____________________________________________________________________________________________ Contact: ______________________________________________________________________________________________ (Work) (Home) (Cell) Social Sec.

#: ___________________________ Date of Birth: _______/_______ /_______ (Day/Month/Year) Please list all members of your household.
Gender: _______Male _______Female NAME SEX AGE RELATIONSHIP TO APPLICANT EMPLOYMENT HISTORY Please provide employment information for the past _____ years, with most recent position held first.
Employer: ______________________________________________________ Phone: ___________________________ Address: _____________________________________________________________________________________________ Supervisor’s Name: ________________________________ Title: ______________________________________ Dates of Employment: __________________________________ to _______________________________ (m/year) 1 Applicant’s Name: __________________________________________________ Position Held: ________________________________________________ Employer: ______________________________________________________ Phone: ___________________________ Address: _____________________________________________________________________________________________ Supervisor’s Name: ________________________________ Title: ______________________________________ Dates of Employment: __________________________________ to _______________________________ (m/year) Position Held: ________________________________________________ Position Held: ________________________________________________ Employer: ______________________________________________________ Phone: ___________________________ Address: _____________________________________________________________________________________________ Supervisor’s Name: ________________________________ Title: ______________________________________ Dates of Employment: __________________________________ to _______________________________ (m/year) Position Held: ________________________________________________ Position Held: ________________________________________________ Employer: ______________________________________________________ Phone: ___________________________ Address: _____________________________________________________________________________________________ Supervisor’s Name: ________________________________ Title: ______________________________________ Dates of Employment: __________________________________ to _______________________________ (m/year) Position Held: ________________________________________________ 2 Applicant’s Name: __________________________________________________ APPLICATION QUESTIONS Please answer all of the following questions as completely as possible.
If more space is needed, use an extra sheet of paper or write on the back of this page.

1.

Why do you want to become a mentor?


___________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 2.
Do you have any previous experience volunteering or working with youth?

If so, please specify: _______________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 3.
What qualities, skills, or other attributes do you feel you have that would benefit a youth?

Please explain: ______________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 4.
Can you commit to participating in the Mentorship aspect of a programme for youths for a minimum of one year from the time you are matched?

_________________________________________________________________________________________________ _________________________________________________________________________________________________ 5.

Are you available to meet with a youth at least up to eight hours per month and have contact at least once per week?

Please explain any particular scheduling issues.


_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 6.

Describe your general health.

Are you currently under a physician’s care or taking any medications?
If so, please explain: _____________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 3 Applicant’s Name: __________________________________________________ 7.

How would you describe yourself as a person?


__________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 8.

How would your friends, family, and co-workers describe you?
________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 9.

Do you drink alcoholic beverages?

If so, what and how often?


________________________________________________________________________________________________ ________________________________________________________________________________________________ 10.

Do you use tobacco products?

If so, what and how often?

_________________________________________________________________________________________________ _________________________________________________________________________________________________ 11.
Have you ever had challenges with substance abuse?

If yes, please explain: ________________________________________________________________________________________________ ________________________________________________________________________________________________ 12.

Do you have any known mental disorders?

If yes, please state.


________________________________________________________________________________________________ ________________________________________________________________________________________________ 13.

Have you ever been investigated or convicted of child abuse or neglect?

If yes, please explain.


________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 4 Applicant’s Name: __________________________________________________ 14.

Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger?
If yes, please explain.

________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 15.
Are you willing to communicate regularly and openly with programme staff, provide monthly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring programme?
________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 16.

Are you willing to attend an initial mentor training session and two in service training sessions per year after being matched?
________________________________________________________________________________________________ ________________________________________________________________________________________________ 5 Applicant’s Name: __________________________________________________ PLEASE READ THIS CAREFULLY BEFORE SIGNING: The Department of Gender Affairs appreciates your interest in becoming a mentor.
Please initial each of the following: _______ I agree to follow all mentoring programme guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.

_______ I understand that the Department is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.

_______ (optional) I agree to allow the Department of Gender Affairs to use any photographic image of me taken while participating in the mentoring programme.
These images may be used in promotions or other related marketing materials.
I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed: • Copy of your valid driver’s license and proof of auto insurance • Information Release Form • Personal References Form • Interest Survey Form • Criminal Record By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
Signature: _______________________________________________ Date: _______________________ Please return or mail this application and the items listed above to: Ms. Kasandra Bedford Department of Gender Affairs Victoria Road 6