AMIGO CENTRE
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E3 Survival Skills for Life Mentor Application
*
Indicates required field
Name (First, Middle, Last)
*
First, Middle, Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Secondary Phone Number
*
E-Mail Address
*
Birth Date
*
Race
*
Marital Status
*
If married, how long?
*
Spouse's Name
*
Number, sex and age of children in the home
*
What is your spouse's/family's reaction to the possibility of you becoming a mentor for E3?
*
Highest grade/level of school completed
*
Degree Received
*
Are you attending school?
*
Where?
*
Area of Study
*
Anticipated graduation date:
*
Have you had experience, paid or voluntary, in dealing with youth? If so, describe
*
Please list any other community involvement or volunteer experience
*
How did you hear about the E3 Survival Skills for Life Program? Please check all that apply:
*
Church
Friend
Community Organization
Newspaper Article
Brochures
Displays
Other
Do you have reliable transportation?
*
Yes
No
Do you have automobile insurance?
*
Yes
No
Do you have a valid Indiana Driver's License?
*
Yes
No
Have you ever served (are currently serving) in the military?
*
What Branch?
*
Date of Service:
*
Have you ever been convicted of a crime? If yes, please explain
*
Have you ever been arrested for driving while intoxicated or driving under the influence?
*
Yes
No
Emergency Contact:
*
First
Last
Relation
*
Phone Number
*
Personal References:
(known for at least one year)
(Please Note: Each person listed must be contacted and complete a short in person or telephone reference before the application can be approved.)
1. Employer (past/current)
*
Email Address:
*
Phone Number
*
Years Known
*
2. Spouse or Family Member
*
Relation
*
Email Address
*
Phone Number
*
3. Name
*
Email Address
*
Phone Number
*
Relationship
*
4. Name
*
Email Address
*
Phone Number
*
Relationship
*
The undersigned acknowledges and agrees that:
(1) he/she is not obligated, if called upon to perform the volunteer services herein applied for, and that GMS or Amigo Centre is not obligated to assign, or actively seek to assign, him/her a mentor for the E3 program.
(2) as a part of the matching process with a mentee, additional information will be elicited from the applicant, and
(3) the above information is true and correct to the best of my knowledge
Signature of Applicant
*
Date
*
Submit
Home
About Us
Staff & Board
Employment
Mission & History
Plan A Retreat
Facilities
Family Retreats
RV & Tent Camping
Lodging
Retreat Planning Guide
Lake Activities
Directions
Programs
Youth Programs
>
Summer Camp
>
Camp Descriptions
Summer Employment
Day Camp
Coming to Camp
FAQ
Winter Youth Retreats
Adult Programs
>
Amigo Golf Scramble
Women and Girls' Retreat
Men's Retreat
Amigo Bike Michiana
Scrap, Craft & Quilt Retreat
Transitional Ministry Training
Family Programs
>
MDS Family Camp
Outdoor Ed
About Our Program
Teacher Information
Curriculum & Activities
Parent/Chaperone Info
Homeschool Program
>
K-5th Curriculum
6th-8th Curriculum
Amigo Trails
O/EE Training Videos
Suggested Reading
CAMP AT HOME
Donate
Events
Volunteer Opportunities
Wishlist
Contact Us
Amigo Park