PAL+ Mentoring Program Application

Thank you for your interest in the PAL+ Mentoring Program. Please complete the following application. Following the return of this application to the PAL+ Mentoring Program Director, Roxanne Bilby, you will be contacted for an interview followed by orientation to the program. Please send your application to Roxanne.B@volunteersforyouth.com or return to the office address listed above. The information you provide in this application will remain confidential.

In this application, you will be asked to report on the following:
●   Identifying Information
●   Employment Information
●   Education Information
●   Personal References
●   Criminal History

You will complete the following:
●   Mentor Questionnaire
●   Mentoring Scenarios
●   Mentor Confidentiality Agreement
●   Mentor Commitment Pledge
●   Mentor Release Statement

You will give the program release to:
●   Contact your personal references
●   Conduct a background check

Instructions for completing your fingerprints are on the final page of this application.

Identifying Information:

First Name *This question is required.

Last Name *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Gender *This question is required.

Street Address *This question is required.

Apt/Suite

City *This question is required.

Zip *This question is required.

How long have you lived at this address? *This question is required.

Email Address *This question is required. This question requires a valid email address.

Primary Phone Number *This question is required. Please provide a 10-digit phone number including area code.
Enter numbers only. Formatting such as dashes will be added as you enter your phone number.

Secondary Phone Number