GBAPP VOLUNTEER/MENTOR APPLICATION

Applications are considered for all volunteer service positions and are treated during service without regard to race, color, religion, sex, national origin, age, marital or veteran status, sexual orientation, medical condition or handicap.

Name:
Current address:
City: / State: / ZIP Code:
Home Phone: / Cell Phone: / E-mail:
Are you 18 years old or older:
YES NO / Gender: F M / Date of Birth: (mm/dd/yyyy):
Have you ever been ARRESTED? YES NOIf so, what for? (Include dates of disposition of case)
Have you ever been CONVICTED of an offense against criminal or military law, forfeited bond or collateral, or are their criminal charges pending against you? YES NO If yes, please state the nature of the conviction, degree of
rehabilitation, and time since release.
Do you have a CURRENTstatus with the criminal justice system such as probation, diversionary program, conditional or unconditional discharge? YES NO If yes, please describe the nature of the involvement.

Emergency Contact

Name:
Address: / Phone:
City: / State: / ZIP Code:
Home Phone: / Work Phone: / Cell Phone:
Relationship:

education

Schools Attended (Name, City & State): / Years Attended / Major/Accomplishment
High School:
College:
Other:

Employment Information

Current employer:
Employer address: / How long?
Phone: / E-mail: / Fax:
City: / State: / ZIP Code:
Position: / Name of Supervisor:

PERSONAL References

Name / Address / Phone Number and E-mail Address

Other Information

Language(s) Spoken:
List of Hobbies/Interests (i.e., sewing, dancing):
Please state what specific times you are available to volunteer. (Include starting date)
How did you hear about the program?
Why do you want to be a volunteer mentor here?
Briefly describe any experience you’ve had working with young people in either a professional or volunteer capacity:
Describe personal strengths:
What do you feel are your limitations?
What are your personal goals?

TRANSPORTATION INFORMATION

Do you have means of transportation? Yes No
Check:
own car, valid license & registration
friend/family car, valid drivers license
bus/train
bicycle/walk

Signatures

Certification: I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that nay misstatement of fact may result in termination. All statements made on this application, including employment information, are subject to verification as condition of volunteer services. I further understand and agree to both a criminal background and DCF background check. I understand that I do not have to agree to this background check, but refusal to do so may exclude me from consideration for some types of volunteer positions and that all such information during the check will be kept confidential.
PrintName:
Signature of applicant: / Date:

Thank you for taking the time to consider volunteering/mentoring for GBAPP; we truly value your support. Please submit all completed applications to:

GBAPP, Inc.

ATTN: Administration

200 Mill Hill Avenue

Bridgeport, CT 06610

or

Email: