KBFLC Mentor Application

7577 Muhly Ct.
Colorado Springs, CO 80915

Basic Details

Namefull name

Namelegal name

Address

City

StateAbbreviation

Zip

Day PhoneInclude Ext

Cell Phone

Evening Phone

Fax

Emaila valid email

Personal Information

Age

Marital Status

Number of Children

Tell us about any hobbies or special interests you may have

Education/Experiences

High School

Post High School

Employer

Current Occupation

select one

Full-time

Part-time

Biography

Please describe yourself brieflyyour moivation for joining the program

How long have you resided in your current home?

Provide all addresses (address, city, state, zip) of places of residence as an adult

What or who moved you to volunteer as a Mentor?check all that apply

Specify Advertisement or Other Here

References: 2 Required

Please list the names, addresses and daytime telephone numbers of two (2) persons (non-family members) who have known you for at least five (5) years either personally or professionally.

Namefull name

Address

City

StateAbbreviate

Zip

Relationship

Phone

Namefull name

Address

City

StateAbbreviate

Zip

Relationship

Phone

Please provide us with one of the following: (Required)

SS#

Colorado Driver's License

Are you confident that you can make a commitment to spend one hour per week for at least one year with a child/teen on a regularly scheduled basis?

Yes

If matched, will you be able to meet our requirement of supervision (weekly short report and telephone contact with a staff member)?

Yes

I understand that I will be working with or in the vicinity of minor children. I understand and hereby authorize any background checks to be performed from one or more private/public sources and/or agencies to determine my suitability for this role. I understand that all information disclosed by background checks will not be shared with me by Kingdom Builders' Family Life Center and shall be used solely for the purpose of volunteer screening and shall not be disclosed to other persons or institutions unless authorized by law.

Application SignatureEnter Your full name

For any questions please contact Lisa Jenkins, BSW, M.Ed/AET, Executive Director, Kingdom Builders' Family Life Center via email at Kingdombuilders0162@yahoo.com