Become a Mentor

01. Mentor Sign-up Form

02. Matching Survey

03. References & Signature

Apply to become a LifeWorks Mentor

Name

Legal Name (if different)

Address

Email

Phone

Mobile Phone

Language(s) Spoken

Date of Birth

MM

/

DD

/

YYYY

Gender

Marital Status

Occupation

Employer

Business Phone

May we contact you at work?

Yes

No

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01. Mentor Sign-up Form

02. Matching Survey

03. References & Signature

Apply to become a LifeWorks Mentor

Race/Ethnicity

Sexual Orientation

Gender Identity

Elementary School

Referred By

Other interests that will be helpful for LifeWorks Staff to know about

What is Mentoring to you?

What is your experience regarding Lesbian, Gay, Bisexual and Transgender (LGBT) youth?

What can you offer a young person as a Mentor?

Explain what “boundaries” mean to you?

What do you think are three of the biggest issues facing Lesbian, Gay, Bisexual and Transgender (LGBT) youth?

What are some of the most important attributes that a mentor should possess?

Why do you want to be a mentor and what do you want to gain from the experience?

Do you have any medical or mental health conditions that LifeWorks staff should be aware of?

What are the best times for you to attend LifeWorks Mentor Training and Support Groups?

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01. Mentor Sign-up Form

02. Matching Survey

03. References & Signature

Apply to become a LifeWorks Mentor

Please list your references below:

Personal Reference (such as relative or friend)

Name

Phone

E-Mail

Address

Professional/ Business Reference

Name

Phone

E-Mail

Address

Professional/Business Reference

Name

Phone

E-Mail

Address

This information is intended to provide preliminary information. Additional information will be obtained by Lifeworks Mentoring Program. I am 21 years of age or older. I hereby authorize the Lifeworks Mentoring to conduct a complete character background check including a Criminal Records, Department of Justice Child Abuse Index registry and Department of Motor Vehicles inquiry.

Digital signature

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