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Home Street Address
Best Time to Call
What age student(s) are you interested in mentoring?
Why do you want to be a CIS mentor? (1-3 sentences)
List previous work or experiences with young people (i.e., scouts, church, community, etc.)
Do you speak a foreign language? If yes, which?
Do you consent to the CIS Mentor Program checking with appropriate public authorities (Department of Social Services’ Child Abuse and Neglect Central Registry, State Police, and Department of Motor Vehicles) for matters of public record regarding your background or history?
Have you ever been convicted of a felony?
Have you ever been convicted of abuse or neglect of a child?
Name of Current Company or Agency
Current Work Supervisor's Name
Business Phone Number
Please list one or two persons, other than relatives, who have known you for at least two years and know you well enough to vouch for your character and/or your ability to work with children and youth. Out of town references are acceptable. Please list complete addresses.
Reference #1 Name
Reference #1 Email
Reference #1 Phone
Reference #2 Name
Reference #2 Email
Reference #2 Phone
The undersigned acknowledges and agrees that (1) he or she is not obligated if called upon to perform the volunteer services herein applied for, and that the CIS Mentor Program is not obligated to assign or actively seek to assign him or her a CIS student; (2) he or she gives permission for CIS to use their still or live photos in promotional materials; (3) as a part of the CIS Mentor Program's matching process, additional personal information may be elicited from the applicant by the Mentor Program Team; (4) the CIS Mentor Program has the applicant's permission to contact references and to conduct background checks with the Department of Motor Vehicles, the State Police and the Child Abuse Registry; (5) he or she will not have contact with the student outside of the planned program; and (6) the CIS Mentor Program reserves the right at all times to terminate any match between any volunteer and student, for whatever cause. I declare that all of the statements made in this application are true, complete and correct to the best of my knowledge and belief.
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