Volunteer (Mentor) Application | Lakes Crisis & Resource Center

Full Name (First, Middle, Last)

Email Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

How long have you lived at this address?

Date of Birth

Age

Place of Birth

Primary Phone

Secondary Phone

Email

Other Addresses

Other Addresses
	Other Addresses Address Address 2 City/Town State/Province ZIP/Postal Code	Item weight

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Please list addresses you have lived at in the last 10 years other than your present address

Family Status

Spouse's or Significant Other's Name

Number of years married/together

Number of Children

How many of these children are currently living with you in your home

Please list the name. age and gender of each child

EMPLOYMENT HISTORY

Employment History
	Employer Telephone Address Job Title Dates Employed Supervisor	Item weight

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EDUCATION

Names & Locations of High Schools, Colleges, Universities, Special Programs	Years Completed	Did you Graduate?	Certificate or Degree Earned	Course of Study	Weight
Names & Locations of High Schools, Colleges, Universities, Special Programs	Years Completed	Did you Graduate?	Certificate or Degree Earned	Course of Study	Item weight
Names & Locations of High Schools, Colleges, Universities, Special Programs	Years Completed	Did you Graduate?	Certificate or Degree Earned	Course of Study	Item weight
Names & Locations of High Schools, Colleges, Universities, Special Programs	Years Completed	Did you Graduate?	Certificate or Degree Earned	Course of Study	Item weight

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Military

Time Served

Branch

Rank

Date and Kind of Discharge

Volunteer Record

List service clubs, fraternal organizations, and volunteer boards to which you belong

Are you affiliated with a church

If yes, name of church

Health

How would you describe your present health

Any physical limitations or concerns

Describe your level of alcohol use

Do you smoke

Have you ever been diagnosed or received treatment for any of the following

Psychiatric Illness

Chemical Dependency

Victim of Abuse

Comments

Transportation

Do you have a valid drivers license?

State

Drivers License #

Do you have your own vehicle?

Make

Model

Year

Color

License Plate #

Do you have current vehicle insurance as required by state law?

Name of Insurance Company

Policy #

REFERENCES

Please give names, complete mailing addresses and phone numbers of at least three references

Name	Relationship	Telephone	# of years known	Address	Weight
Name	Relationship	Telephone	# of years known	Address	Item weight
Name	Relationship	Telephone	# of years known	Address	Item weight
Name	Relationship	Telephone	# of years known	Address	Item weight

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Authorization:

I understand that Kinship reserves the right to use the information provided by myself, references, and public records to determine my involvement in the Kinship program. This information is confidential to the Kinship staff and screening committee. I understand that misrepresentation of personal information or history could result in termination or non-acceptance in the Kinship program.

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