OreMi Mentor Application

Thank you for your interest in the OreMi Mentoring Program. OreMi's thorough screening process ensures the safety of our children, families and mentors, and the best possible matches for our prospective mentees and mentors.

Please note: The information you provide on this application will be kept confidential and is used strictly to determine your eligibility in the Mentoring program. Submitting an application to the OreMi Mentoring Program does not guarantee acceptance or matching in our program.
A. Program Requirements:
1. Are you at least 18 years old?

2. Can you commit to participate in the OreMi Mentoring Program for a minimum of one year from the time you are matched with a mentee?

3. Are you available to meet with a mentee for at least 1 hour per week?

4. This Mentoring Position requires that mentors receive a clearance in the following areas: criminal record, child abuse and sexual offender. Are you willing to allow us to conduct a background check in the areas listed above?

5. Are you willing to communicate regularly and openly with OreMi Program Staff and receive feedback regarding your mentoring activities?

6. This mentoring position requires you to attend an initial Mentor Training, two in-service training sessions per year after being matched, and to set goals with a mentee once you are matched. Can you meet this requirement?

If you meet these requirements, please proceed in completing the application. If you cannot fulfill these requirements, please complete section B only.
B. General Information
Full Name

First NameMiddle NameLast NameSuffix
Email Address
Re-enter Email Address:
Work Phone:

Area CodePhone Number
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I prefer to be contacted:
C. Personal Information
Date of Birth:

MonthDayYear
Gender:
Preferred Pronoun:
Marital Status:
Ethnicity (Please select all that apply):
If Other, please specify:
Do you speak any language other than English? if so, please list:

Please list all members of your household in which you currently live:

Rows	Name	Gender	Date of Birth	Relationship to Self
1.
2.
3.
4.

D. Education/Employment History
What is your highest level of education completed:
What is your current employment status? (Check all that apply)
What is your current occupation?
If you are currently employed, who is your employer?
E. Background

(Note: An answer of "yes" to any of these questions will not automatically disqualify you from the program.)
Have you ever had an alcohol or substance abuse problem? If yes, please explain.
Have you ever been arrested or convicted of a crime? If so, please explain and list dates.
In the past five years, have you been convicted of a DUI or had your license suspended, or had any other incidents relating to your driving record?
F. Match Preferences
Why do you want to become a mentor?
List any hobbies or interests you would like to share with a mentee.
Please list 5 words that describe your personality.
What kind of experience do you have working with or being around children?
In order to help us best match you with a mentee, please select your preference(s), if any. Please select all that apply.
Age:
Ethnicity:
If other, please specify:
Would you be willing to work with a child with special needs?
If yes, please specify:
Do you have your own transportation (other than a motorcycle)?
Is your vehicle insured and in good working condition?
Please note: If you do not have access to an insured vehicle, we may not be able to find a mentee within a reasonable travelling distance which severely limits opportunities for a mentor-mentee match.
How did you first hear about OreMi? (Please select all that apply, and specify below.)
Specify Here
I understand that FSSBA is not obligated to provide a reason for their decision of accepting or rejecting me as a mentor in the OreMi Mentoring Program. By checking this box, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
Should be Empty:

A. Program Requirements:

B. General Information

C. Personal Information

D. Education/Employment History

E. Background

F. Match Preferences