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Newberg Mentors

PO Box 91, Newberg, OR. 97132


(503)453-7967

Mentor Application
Date_____________________
Are you applying to be a:
Mentor _____ Tutor _____
Name______________________________________________________________________________________
Last
First
Middle initial
Birthdate _____/_____/_____ Age ____ Gender ____ Social Security Number ______-______-______
Cell ( _____) ______-_______ Home Phone ( _____) ______-_______
Email ___________________________________
Address ____________________________________________________________________________________
Street
City
State
Zip
Place of Employment/School Attending ___________________________________________________________
Work Phone ( ____) ____-_____ Can you be called at work? _____ Work Hours ______
Employment History
List your employment history for the last 5 years, beginning with your current position.
Employer
Date Employed
Title
Reason For Leaving
FT/PT
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Educational Background
Please list the names of schools attended, with anticipated/actual graduation date, degree achieved.
___________________________________________________________________________________________
High School
___________________________________________________________________________________________
College
___________________________________________________________________________________________
Technical/Trade
Single _____

Married _____

Divorced _____ Separated _____ Widowed _____

Can you provide your own transportation? _____ Do you have insurance? _____
Please list your auto insurance company and limits of liability.
___________________________________________________________________________________________
___________________________________________________________________________________________

Mentor/Mentee Activities and Interests


Place an X next to the activities you enjoy doing. Leave blank, items you have absolutely no
interest in. Please circle your top 5 choices.
Sports
___ Moto Cross
___ Football
___ Baseball
___ Basketball
___ Track
___ Soccer
___ Ping Pong
___ Tennis
___ Volleyball
___ Roller skating
___ Bowling
___ Billiards
___ Swimming/diving
___ Auto racing
___ Wrestling
___ Golf (regular/mini)
___ Handball
___ Hockey
___ Archery
___ Frisbee
___ Racquetball
___ Downhill Skiing
___ Sledding
___ Snowmobiling
___ Marital Arts
___ Cross Country Skiing
___ Ice Skating
___ Ice Fishing
___ Weightlifting

Recreation
___ Auto mechanics
___ Walking
___ Hiking
___ Camping
___ Fishing
___ Cooking
___ Picnicking
___ Boating
___ Canoeing
___ Water Skiing
___ Horseback riding
___ Rodeos
___ Motorcycling
___ Bike riding
___ Jogging/running
___ Listens to music
___ Movies
___ Museums
___ Plays
___ Concerts
___ Dancing
___ Reading
___ Stamp Collecting
___ Coin collecting
___ Rock Collecting
___ Model Cars
___ Indoor Games
___ Video Games
___ Musical Instrument
___ Playing Cards
___ Pool, pinball, foosball
___ Singing
___ Acting

Science/Technology
___ Study Nature
___ Animal tending/zoo
___ Gardening
___ Rock Climbing
___ Travel/sightseeing
___ Chemistry
___ Astronomy
___ Electronics
___ Computers
___ Photography
Other
___ Attending church
___ Speaking foreign
languages
Arts & Crafts
___ Carving
___ Sewing
___ Crocheting
___ Quilting
___ Woodworking
___ Knitting
___ Macram
___ Painting

References
Please list 3 references of people you know well. Your references should include male and female, and a
supervisor or teacher. Information will be kept confidential.
Name
1.

Address

City/State/Zip

Relationship

phone

2.
3.
Why do you want to be a mentor? What do you feel will be your role as a mentor?

Please describe the experience, skills, talents, or qualities you have that make you a good candidate for mentoring a
child in this program?

The primary purpose of Newberg Mentors is to provide the friendship of a mature and well-adjusted adult to a child
who can benefit from such a relationship. Please complete the following questions. This information is confidential
and is used with professional discretion to understand your growth experiences.
1. Do you have any physical or mental problems, which would limit participation? No ____ Yes ___
If so, please explain and give agency name and/or professional from which you have received service.
Name _______________________ Address ______________________________ Dates ___________
1. Have you ever received any psychological treatment or counseling? No ____ Yes ____
If so, please explain and give agency name, address and professional from whom you have received service, when
service began and ended.
Name _______________________ Address ______________________________ Dates ___________
2. Have you ever been involved, arrested, or convicted of a misdemeanor or a felony (this includes alcohol and drug
related charges?) No ____ Yes ____ If yes, please list nature of offense and the date.
_____________________________________________________________________
3. Have you ever been arrested and/or convicted of a crime that involved a minor? No ____ Yes ____
Is so, please explain __________________________________________________________________

I acknowledge and agree that I am not obligated, if called upon, to perform the volunteer services herein applied for,
and that Newberg Mentors is not obligated to assign or seek to assign me to a mentee. I understand that if approved I
agree to fulfill the commitment to my chosen program.
I understand that as a part of the matching process, additional personal information will be elicited from me by the
agency and professional staff through an interview. I certify that my statements in the application are true, complete
and correct to the best of my knowledge and belief. I hereby authorize Newberg Mentors to contact the references
listed on the application form and to conduct whatever investigation it may deem necessary to determine if I can
become an effective mentor.
Signature ___________________________________________________ Date _____________________