Mentorship Application

APPLICANT PERSONAL INFORMATION

Name *

First

Last
Date of Birth *

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Phone Number *

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Cell Number *

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Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Are you a Canadian citizen? *
 Yes 
 No 
If not, are you entitled to work in Canada?
 Yes 
 No 
What country were you born? *

EMPLOYMENT INFORMATION

Current Employer *
Employer Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
How long you've been with your current employer? *
Phone Number *

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Fax Number *

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Email *

EMERGENCY CONTACT

Name *

First

Last
Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone Number *

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Relationship *

REFERENCES

At least 3 references are required.
1. Reference Name *
Address *
Phone Number *

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2. Reference Name *
Address *
Phone Number *

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3. Reference Name *
Address *
Phone Number *

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REASON(S) YOU WANT TO BE A MENTOR

Please state your reason(s) for wanting to become a youth mentor.
State Reason(s) *

PREVIOUS VOLUNTEER EXPERIENCE

Indicate Experience *

POLICE CHECK

Please note that you will need to perform an onerous police check prior to starting the mentorship program. Proof will be required.

DISCLAIMER

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to Mentorship, I understand that false or misleading information in my application or interview may result in my release
Your Signature *
Type Full Name
Agreement *
 Agree 
 Disagree 
Select to authenticate signature
Date *

MM
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DD
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YYYY
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