Dear Potential Mentor,

At this time,  we have put a hold on accepting any new applications for One on One Mentoring.  We would be happy to accept your application with our other mentoring organization, Mentoring Tucson's Kids.  Please visit that website www.mentoringtucsonskids.org and complete the process there.  We are sorry for this inconvenience.  If you have any questions please give me a call at 520-624-4765 ext 1.

Sincerely,

Andrea Williams

Mentor Coordinator

To view Frequently Asked Questions by mentors, click here.  

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Mentor Application
Date
Nameyour full name
Your Age
Date of Birth
Home Phone
Cell Phone
Address
City
Zip
Marital Status
Spouse’s Name
Age
Children:Name & Age
Children:Name & Age
Children:Name & Age
Children:Name & Age
Present Employer/ Company
Address
Phone Number
Position
How Long Employed?
Supervisorfull name
List Other Employment (Most Recent First)
Employer
Position
How Long Employed
Reason for leaving
Employer
Position
How Long Employed
Reason for leaving
Employer
Position
How Long Employed
Reason for leaving
How Many Times have you moved in the past 5 years?
List Past Residences (Most Recent First)
Address
City/State/ZIP
How Long In Residence
Address
City/State/ZIP
How Long In Residence
Address
City/State/ZIP
How Long In Residence
Education
High School
Years Attended
Graduate?
College/ University or Technical Training
Years Attended
Degree
Have you ever applied to be (or have been) a mentor our program before?When?
If yes, explain:more details
0 /
Past experiences with children/youth:more details
0 /
Health:
Any physical limitations or special concerns?
0 /
Are you taking medications on a regular basis?
Any known allergies?
Have you ever sought counseling/therapy or treatment for any reason?
Date(s):
Please explain:more details
0 /
Explain your present use of alcohol or any other drugs:
0 /
Do you have a valid driver’s license?
State
Number
Do you have your own transportation?
License Plate Number
Model & Year of Vehicle
If no, do you have access to transportation?
Describe
Do you have current vehicle insurance as required by Arizona’s law?
Company
Policy Number
Please describe your driving record and offenses:
0 /
I will promptly report to One on One any changes in my insurance coverage or driver’s license status.
Signature
Date
Have you ever been a victim of a crime?
If yes, please explain
0 /
Have you ever been involved, investigated, arrested and/or convicted of an assault?
If yes, When:
Explain:
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Have you ever been involved, investigated, arrested and/or convicted of child abuse, neglect or sexual molestation of a minor?
If yes, When?
Explain:
0 /
List four references (one present or past employer, one friend you have known for at least two years, a spouse or significant other and one relative.) If you have recently been, or currently are in counseling, therapy/treatment, substitute the name of your therapist for your friend reference or significant other reference.
Name
Relationship:
Address:
City
State & ZIP
Phone:
Name
Relationship:
Address:
City
State & ZIP
Phone:
Name
Relationship:
Address:
City
State & ZIP
Phone:
Name
Relationship:
Address:
City
State & ZIP
Phone:
Be sure to attach a copy of your driver’s license and your current auto insurance to this application Be sure to sign at the bottom.
What attitudes and beliefs are of special importance to you?
0 /
Please list interests, hobbies, and activities that you pursue:
0 /
Do you have any special skills or talents you’d be willing to share?
0 /
What languages other than English to you speak?
0 /
I understand that One on One will contact the above listed references, and any other persons deemed necessary. I agree to a background check and driving record check(s) and will provide One on One with a copy of my driver’s license, proof of car insurance, and a set of fingerprints by an official department. I understand that any misrepresentation of personal information or history in this application could result in termination or non-acceptance in the One on One program.
Signature
Date
Social Security Number
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