Mentor Application
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Welcome Back Tarrant County Mentor Application Cornerstone Network Assistance
Mentor Name: First
M.I
Last
Street
City
State
Address:
Phone: ( )
( Home
)
(
Zip Code
)
Work
Cell
Email: Driver’s License Number:
State Issued:
Gender: Male/Female ……… Marital Status: Single Married Divorced Separated Widowed Hours Available per Week (circle): 3 4 5 6 Hours per Month: 12 16 20 24 Ethnicity:
What Language Do You Speak: Eng., Spanish. Other
Church/Organization Affiliation: Church/Organization Address: StreetCityStateZip Code Church/Organization Phone#:
(
)
Have you ever been charged with or convicted of a misdemeanor or felony (other than traffic violation)? Yes No If so, briefly explain charge(s).
Briefly explain why are you interested in being a mentor?
Weclome Back Tarrant County Mentor application (cont.)
Do you attend services regularly? Yes
2009
No Please share with us what church activities you are
actively involved in?
Does your church have a Prison Ministry? If not, how will your church support your mentoring efforts?
Can you commit to at least three (3) hours per week to your mentoree for at least one (1) year? Yes
No
Does your family support your mentoring? Yes
No
Are you continuing to grow in your Christian walk? Yes
No
Are you willing to provide references for your mentoree? Yes
No
What mentoring or prison ministry experience do you currently have?
Have you completed your mentor training? Yes date(s) completed:
No If so, please provide type(s) of training and
Training
Have you completed the TDJC three (3) hour training course? Yes
Date Completed
No
Welcome Back Tarrant County Mentor Application | Confidential
Weclome Back Tarrant County Mentor application (cont.)
Are you an ex-felon? Yes
2009
No If yes, please provide facility information:
Prison Name & Location
Are you currently on parole or probation? Yes
Dates
No
If yes, please provide your Parole Officer’s name: When does your parole end? Please share any hobbies or other skills you have?
I understand that the information given by me in this application will be verified and that any false or omission of facts associated with this application may result in either denial of mentoring or dismissal from the Welcome Back Tarrant County Mentor Program. I certify that the answers and statements given by me on this application are complete and true to the best of my knowledge and credence. Signature
Date:
Welcome Back Tarrant County Mentor Application | Confidential
Mentor Name: First
M.I
Last
Street
City
State
Address:
Phone: ( )
( Home
)
(
Zip Code
)
Work
Cell
Email: Driver’s License Number:
State Issued:
Gender: Male/Female ……… Marital Status: Single Married Divorced Separated Widowed Hours Available per Week (circle): 3 4 5 6 Hours per Month: 12 16 20 24 Ethnicity:
What Language Do You Speak: Eng., Spanish. Other
Church/Organization Affiliation: Church/Organization Address: StreetCityStateZip Code Church/Organization Phone#:
(
)
Have you ever been charged with or convicted of a misdemeanor or felony (other than traffic violation)? Yes No If so, briefly explain charge(s).
Briefly explain why are you interested in being a mentor?
Weclome Back Tarrant County Mentor application (cont.)
Do you attend services regularly? Yes
2009
No Please share with us what church activities you are
actively involved in?
Does your church have a Prison Ministry? If not, how will your church support your mentoring efforts?
Can you commit to at least three (3) hours per week to your mentoree for at least one (1) year? Yes
No
Does your family support your mentoring? Yes
No
Are you continuing to grow in your Christian walk? Yes
No
Are you willing to provide references for your mentoree? Yes
No
What mentoring or prison ministry experience do you currently have?
Have you completed your mentor training? Yes date(s) completed:
No If so, please provide type(s) of training and
Training
Have you completed the TDJC three (3) hour training course? Yes
Date Completed
No
Welcome Back Tarrant County Mentor Application | Confidential
Weclome Back Tarrant County Mentor application (cont.)
Are you an ex-felon? Yes
2009
No If yes, please provide facility information:
Prison Name & Location
Are you currently on parole or probation? Yes
Dates
No
If yes, please provide your Parole Officer’s name: When does your parole end? Please share any hobbies or other skills you have?
I understand that the information given by me in this application will be verified and that any false or omission of facts associated with this application may result in either denial of mentoring or dismissal from the Welcome Back Tarrant County Mentor Program. I certify that the answers and statements given by me on this application are complete and true to the best of my knowledge and credence. Signature
Date:
Welcome Back Tarrant County Mentor Application | Confidential
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