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  Who Is A Peer Mentor?
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Fields marked * are required.

PERSONAL HISTORY

First Name *
Last Name *
Sex *
Date of Birth * (dd/mm/yy)
Place of Birth
Nationality*
Mailing Address *
Parish and PostCode
Current Employer
Occupation
Home Phone *
Work Phone
Mobile Phone
Fax Number
E-mail Address

EMPLOYMENT HISTORY

List the last two places of employment with the most recent first:

Company One:

Company
Company Phone
Date (dd/mm/yy)
Company Address

Company Two:

Company
Company Phone
Date (dd/mm/yy)
Company Address

REFERENCES

References should be from one family member and one non-family member

Professional Reference:

Name
Phone

Personal Reference:

 
Name
Phone
 

PERSONAL DETAILS

Education Level
What form of transport do you have access to?
Are you parent/ guardian of any children under the age of 18 *
If so, what age(s)?
Special Skills (e.g. languages, computers, etc.)

Hobbies and sports that may be helpful in matching you and your mentee (e.g. soccer, cricket, music, art, etc.)

Do you have any previous experience as a volunteer?
If so, where?
Please list and other Clubs or Organisations to which you belong:

What do you see as the three most important issues facing Bermuda today?
1.
2.
3.
Please write a brief statement on why you wish to be a volunteer and what you hope to gain by enrolling in the YouthNet mentoring program:

If selected as a mentor, what would be your preference of day - First Choice

- Second Choice
Which programme are you interested in?
Do you have any questions regarding this program?
How did you hear about YouthNet?

MENTOR RELEASE STATEMENT

I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of YouthNet Mentor Programme. I understand the programme involves spending a minimum of one hour each week at the assigned school with my mentee from September to June. Further, I understand that I will attend an orientation session, be involved in training during the year, and communicate with the teacher regularly during this period. I will be committing one school year in the program and will then be asked to renew for another year. I have not been convicted, within the past ten years, of any felony or misdemeanor classified as an offense against a person or family, of public indecency, or a violation involving a legally controlled substance. I am not under current indictment. Further, I hereby fully discharge school personnel, participating companies or organisations from any and all liability, claims, cause of action, cost and expenses which may be attributable to my participation in the Program.

I understand that the Mentor/Mentee relationships established generally take place during the confines of the school day, usually during lunch time. I further understand that permission is needed to establish mentor/mentee contact outside of regular school hours.

I have read the above Release Statement and agree to its contents. To the best of my knowledge and belief, all statements in this profile application are true and accurate.

 

 

 

 

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