Reach & Rise Mentor Application

Thank you for your interest in becoming a mentor with the Reach & Rise mentoring program. It is a great way to make a difference in a young person’s life. This application is designed to provide information to help us match you with the most appropriate child and your answers will be kept confidential. For security & safety purposes, all mentor applicants will need to have fingerprints or background checks completed and cleared before being matched with a youth. If you have any questions please contact the Program Director.

Please email or hand deliver a copy of your driver’s license and insurance to:

Program Director: Brittany Lindsey
YMCA of Greater Birmingham Al
2400 7th Avenue North
Birmingham Al 35204
Phone: 205-223-1084
Email: blindsey@ymcabham.org

Today's Date*

Mentor Information

Name*

First Last

Age*

Please enter a number greater than or equal to 21.

Date of Birth*

Gender*

Female

Male

Personal Gender Pronoun

Address*

Street Address Address Line 2 City State ZIP Code

Home #

Work #

Cell #*

Email Address*

Enter Email Confirm Email

Best Way to be Contacted:*

Best Time To Call You

When is the best time for us to reach you?

Occupation

How did you hear about us?

Please answer the following questions:

Do you have any felony convictions or misdemeanors?*

Yes

If yes:*

Have you ever abused or molested a child?*

Yes

Do you have a clean driving record?*

Yes

If no:*

If you have a car, can you provide proof of liability car insurance?*

Yes

Why do you want to become a Mentor?*

Would you be a positive role model to a child? What qualities do you have that will help mentor a child?*

Why do you think children "act out" or get in trouble?*

Do you have any experience working with, volunteering, or spending time with youth? If yes, explain:*

Please describe any other volunteer experiences you have:*

Do you have any academic pursuits/experience that is related to working with youth? If yes, explain:*

Who was a mentor for you as a child? What qualities did they have that helped you?*

Please describe your relationships with your family (e.g. parent(s)/guardian(s), siblings, etc.) both past & present. Include how you were disciplined as a youth and by whom.*

Please describe your relationship with a best friend and/or significant other?*

Please describe past and current patterns of drug and alcohol use:*

What are some of your interests & hobbies (things you would like to do with your mentee)?*

Do you have a preference as to the age, race/ethnicity, gender, sexual orientation, special needs, religious beliefs, political affiliation, socioeconomic background, or geographic location of the youth you’d work with?*

References

The YMCA checks references for all volunteers and the Reach & Rise® Mentoring Program requires 2 Personal References & 2 Professional References. The following information is required of all applicants.

Personal References*

Name

Phone

Relationship to you?

How long have you known this person?

Personal References*

Name

Phone

Relationship to you?

How long have you known this person?

Professional References*

Name

Phone

Relationship to you?

How long have you known this person?

Professional References*

Name

Phone

Relationship to you?

How long have you known this person?

Mentor Applicant Signature*

First Last

Date*

Reach and Rise Mentor Application

Mentor Information

Please answer the following questions:

References

Find your
fitness at
the Y

Find your
friends at
the Y

YMCA of Greater Birmingham

Reach and Rise Mentor Application