Name		Date
Home Address:		Best Time to Reach You:	morning afternoon evening
Social Security Number:		Home Phone:		Work Phone:
Driver License #:		Issuing State:
Occupation:		Employer Name and Address
Briefly Describe Your Current Occupation:
Do you have other time or work constraints for Volunteer activities?		yes no
Explain:
Education and other Skills:
Interests and Hobbies:
Previous work or experience with youth (Scouts, church, club, school, etc)
What strengths do you bring to the Volunteer/Mentor process?
How did you hear about the Volunteer Program?
Have you ever been convicted of a felony?	yes no
If yes, please explain:
Please list two references that have known you for at least two years. (By supplying this information you are granting us permission to contact the individuals listed.)
Reference:
Address:
Home Phone:		Work Phone:
Reference:
Address:
Home Phone:		Work Phone:
Terms of the Volunteer/Mentor Program: Attend orientation and training sessions Have a sincere desire to help troubled youth Report as scheduled Maintain confidentiality Notify appropriate staff if you cannot be where you've committed to be when you've committed to be there
By submitting this form I agree to all of the conditions stated above and hereby grant permission for Wings For Life to conduct full criminal, MVR, and reference checks as required.