Mentor Application Form

Mentor Application

Thank you for your interest in becoming a volunteer mentor. Please answer the following questions and click the “SUBMIT” button at the end of the form to submit (or download the PDF to fill out later). Next, download, complete, and sign the background check authorization form, and return to our office.

Telephone Number
E-Mail Address:

Applicant Information:

Are you employed outside the home?
Please list your current or most recent occupation/employer:
May we call your employer as a reference?
YesNo If "No," please explain:
Contact: Phone
Identify your education (i.e. high school diploma, bachelor's degree, etc.) and/or military service:


Give three references you’ve known for at least 1 year, including one relative (other than a spouse or child):
Reference #1
Reference #2
Reference #3

Additional Information

Talbot Mentors asks participants to join its program for a minimum of one year with the goal of meeting for 1-2 hours a week. Are you able to make this commitment? YesNo
Have you been convicted of a crime against another person or judicially determined to have committed abuse or neglect of a child? YesNo
If you answered yes to either of these questions, explain:
Auto Insurance: