Mentor Application Reference Form
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Welcome Back Tarrant County Mentor Reference Form Cornerstone Network Assistance
Mentor Name: First Phone: ( )
M.I (
Last
)
Home
(
)
Work
Cell
The above mentioned person has applied to be a mentor with the Welcome Back Tarrant County Mentor Program. Your evaluation will help WBTC decide how to best use this person. We will thank you in advance for your time and assistance in completing this form, and returning it back to our office. Your Full Name: Phone: ( )
( Home
)
( Work
) Cell
What is your relationship to the mentor applicant? How long have you known this person? To the best of your knowledge, do this mentor candidate attend church services regularly, and participate in ministry or church functions? Yes
No
What gifts or talents do you believe this candidate has that would make them a appropriate mentor?
Have you ever experienced this individual has with dealing with difficult relationships or conflicts?
2009
Weclome Back Tarrant County Mentor Reference Form (cont.) In your opinion, would you distinguish this person as a “mature” Christian, and ready to reach out to others? Explain your answer please?
On a scale from 1 to 10, one being the least, how would you rate this person’s home, work, and church life? 1
2
3
4
5
6
Would you allow this person to watch your children? Yes
7
8
9
10
No
The only way possible to have a successful mentoring program is to have the assistance of someone else. Will you be willing to provide the necessary support? Yes Does the mentor’s church have people to help? Yes
No
No
Do you know of anyone else who may be able to assist this person? Yes
No
Do you have any reason why you would NOT recommend this person? Yes
No
If yes, please explain?
I do recommend
to serve as a mentor to
someone who has been impacted by incarceration. I feel this person has the necessary maturity and commitment to carry out this mentor assignment and is capable of demonstrating God’s love. He/she is also capable of confronting in love when necessary and can work as a team player.? I agree to pray for this relationship between the mentor and the mentoree? Yes I do not recommend
Signature
No
to become a mentor at this time.
Date:
Welcome Back Tarrant County Mentor Reference Form | Confidential
Weclome Back Tarrant County Mentor Reference Form (cont.) Please return this completed form to: Welcome Back Tarrant County Attn: Michael Winfrey Cornerstone Assistance Network 3500 Noble Avenue Fort Worth, TX 76111 Phone: 817-632-6000 Ext. 125
Welcome Back Tarrant County Mentor Reference Form | Confidential
2009
Mentor Name: First Phone: ( )
M.I (
Last
)
Home
(
)
Work
Cell
The above mentioned person has applied to be a mentor with the Welcome Back Tarrant County Mentor Program. Your evaluation will help WBTC decide how to best use this person. We will thank you in advance for your time and assistance in completing this form, and returning it back to our office. Your Full Name: Phone: ( )
( Home
)
( Work
) Cell
What is your relationship to the mentor applicant? How long have you known this person? To the best of your knowledge, do this mentor candidate attend church services regularly, and participate in ministry or church functions? Yes
No
What gifts or talents do you believe this candidate has that would make them a appropriate mentor?
Have you ever experienced this individual has with dealing with difficult relationships or conflicts?
2009
Weclome Back Tarrant County Mentor Reference Form (cont.) In your opinion, would you distinguish this person as a “mature” Christian, and ready to reach out to others? Explain your answer please?
On a scale from 1 to 10, one being the least, how would you rate this person’s home, work, and church life? 1
2
3
4
5
6
Would you allow this person to watch your children? Yes
7
8
9
10
No
The only way possible to have a successful mentoring program is to have the assistance of someone else. Will you be willing to provide the necessary support? Yes Does the mentor’s church have people to help? Yes
No
No
Do you know of anyone else who may be able to assist this person? Yes
No
Do you have any reason why you would NOT recommend this person? Yes
No
If yes, please explain?
I do recommend
to serve as a mentor to
someone who has been impacted by incarceration. I feel this person has the necessary maturity and commitment to carry out this mentor assignment and is capable of demonstrating God’s love. He/she is also capable of confronting in love when necessary and can work as a team player.? I agree to pray for this relationship between the mentor and the mentoree? Yes I do not recommend
Signature
No
to become a mentor at this time.
Date:
Welcome Back Tarrant County Mentor Reference Form | Confidential
Weclome Back Tarrant County Mentor Reference Form (cont.) Please return this completed form to: Welcome Back Tarrant County Attn: Michael Winfrey Cornerstone Assistance Network 3500 Noble Avenue Fort Worth, TX 76111 Phone: 817-632-6000 Ext. 125
Welcome Back Tarrant County Mentor Reference Form | Confidential
2009
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