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Become a Mentor
Host a Workshop
Donate
About
Our Mission
Our Marcy Houses History
Our Board
Awardees & Donors
Contact
Events
FAQs
News
Apply
Resources
Ways to Help
Become a Mentor
Host a Workshop
Donate
Donate
Volunteer Mentor Application
All fields are required.
Name:
First Name
Last Name
Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone:
(###)
###
####
Mobile Phone:
(###)
###
####
Name/address of employer:
Work Phone:
(###)
###
####
Occupation:
Email Address:
Gender:
Birth Date:
MM
DD
YYYY
Educational Background (mark one):
Some high school
High school graduate
Some college
Graduate/professional school
Technical school
College graduate
Other
If Other, please specify:
What other languages do you speak?
Please list any hobbies or interests you may have:
VOLUNTEER INFORMATION:
How did you hear about the Marcy Houses Mentoring Program?
What current involvement do you have with young adults?
Write a brief statement on why you have chosen to participate in the Marcy Houses Mentoring Program.
Please indicate your understanding by typing your initials below each of the following two statements:
I understand that the Marcy Houses Mentoring Program involves a time commitment of up to three hours per month.
I understand that I will be required to complete the mentor orientation session.
MENTOR PREFERENCES:
What days of the week are you available to volunteer? (check all that apply):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is the best time for you to volunteer? (check all that apply):
Mornings
Afternoons
Evenings
Weekends
Do you have a gender preference?
No
Yes
If yes, please specify:
Do you prefer working with a student from a specific racial/ethnic group?
No
Yes
If yes, please specify:
REFERENCES:
Please list three references (At least one should be a work reference including an immediate supervisor):
Reference #1:
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number:
(###)
###
####
Relationship:
Reference #2:
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number:
(###)
###
####
Relationship:
Reference #3:
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number:
(###)
###
####
Relationship:
SCREENING INFO:
In making this application to be a volunteer, I understand that the Marcy Houses Memorial Scholarship Fund may perform criminal checks of volunteers.
Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance?
Yes
No
Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in question #1?
Yes
No
Have you ever had a license to engage in any profession revoked or suspended?
Yes
No
If the answer is YES to any of the above questions, please explain below:
I certify to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and on subsequent mentor application forms, is grounds for dismissal.
Full Name
Date
MM
DD
YYYY
Thank you for your mentorship application submission!
