Name
*
First Name
Last Name
Birthdate
*
MM
DD
YYYY
Gender:
*
Male
Female
Other
Phone
*
(###)
###
####
Email
*
Name/Address of Employer:
*
Work Phone Number
*
Occupation:
*
Indicate your grade preference:
*
Where did you hear about us?
*
Why do you want to become a mentor and why have you chosen to participate in Stable Moments?
*
What do you feel are the strengths ( horse knowledge, previous relevant volunteer or work experience, etc.) you can bring to Stable Moments?
*
What do you hope to gain personally from being a Stable Moments mentor?
*
What concerns do you have regarding your participation in the program?
*
Please check the two following statements below:
*
Within the last 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance?
*
Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in the previous question?
*
If the answer was YES to the two previous questions, please explain below:
Educational Background (mark one):
What days of the week are you available to mentor? (check all that apply):
*
What is the best time for you to mentor? (check all that apply):
*
Do you prefer working with a:
*
Girl
Boy
No Preference
Do you prefer working with a quiet, reserved child?
*
Yes
No
No Preference
Do you prefer working with an outgoing child?
*
Yes
No
No Preference
Do you speak a foreign language?
*
Yes
No
If yes, please specify:
Please list any hobbies or interests you may have:
*
My favorite subject in school was:
*
My least favorite subject in school was:
*
Please check any of the activities you enjoy the most:
*
What qualities would you like in a participant?
*
What individual has served as a role model for you? Why?
*
If you could recommend one book for you participant to read, what would it be?
*
Photo Consent
*
I consent to and authorize the use and reproduction by Justin's Place of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Confidentiality Agreement
*
I understand that all information (written and verbal) about participant at this center is confidential and will not be shared with anyone without expressed written consent of the participant and his/her parent/guardian in the case of a minor.
