Name (required):

Birthdate:

Address (required):

E-mail (required)::

Telephone (required)
Alternate Telephone

Driver's License Number (required)

Social Security Number (required)
- -

Marital Status:

Spouses Name:
Is your spouse going to be a part of the mentorship?
Yes No

Spouse's Social Security Number:
- -

Spouse's Driver's License Number:

Why do you want to be a mentor to children?

What do you feel that you can offer a child as a mentor?

Have you ever worked with children?
Yes No

Where?

How Long?

Do you have children of your own?
Yes No
What are their ages?

Will they be involved in the mentorship?
Yes No

What church do you attend?

How Long?

Please give a brief summary of your statement of faith.

What is your occupation?

Do you have an age preference of the child?
Yes No

If so:

Do you have a preference on a male or female child?
Yes No

If so:

BACKGROUND CHECK INFORMATION
Please note that we will be conducting criminal background checks on all of its mentor applicants.

Have you (and/or spouse) ever been convicted of any offenses by a civilian or military court? Yes No

Have you been or are you now being charged with any criminal offense, or are there any civil courts actions or judgments now pending against you?
Yes No

If you answered “yes” to either of the above questions, please provide details. State the date and place of each arrest, court action or judgment. Give the nature of the charge or court actions, and current status of disposition including any sentence or fine imposed. Provide a complete explanation of the circumstances.

Have you ever been treated for alcohol or drug dependency? Yes No
If you answered “yes,” please list date(s) and place(s) of treatment

References: (if your spouse is involved references for both)

Name:

Phone:

Address:

Name:

Phone:

Address:

Name:

Phone:

Address:

Is it ok if we contact your references? Yes No

FINAL TERMS OF ACCEPTANCE

• I understand that being a Mentor is an undertaking requiring responsibility, integrity, patience and commitment.
• I understand the need to provide references and herby give permission for Grace Centers of Hope to contact individuals whose names I have listed on this application.
• I understand that Grace Centers of Hope will also conduct a criminal background check on me.
• I release Grace Centers of Hope, directors, employees, agents and representatives from any and all liability whatsoever relating to the disclosure or use of my criminal offender record obtained, if any, pursuant to the State laws or other laws.
• I also hereby release and agree to hold harmless from liability any person or organization that provides information concerning me to Grace Centers of Hope.
• I understand that all of the information that I have provided may be verified.
• I certify that all the statements made in this application are true, correct and complete to the best of my knowledge and are made in good faith.
• I understand that if any of the above information changes on my application that I am responsible to inform Grace Centers of Hope in writing of those changes as soon as they occur.
• I understand that any misinformation may be cause for disqualification or termination.

I accept and agree to the above terms of acceptance.