Mentor Application

Full Name

Date of Birth Sensitive

Home Address Sensitive

Phone Number

Email Address

Occupation / Employer

Emergency Contact Name & Number

How many hours per week can you commit?

2–4 Hours 5–8 Hours 8+ Hours

Preferred Availability

Weekdays Evenings Weekends

Are you able to commit for at least 6 months?

Yes No

Do you have experience working with youth?

Yes No

If yes, explain briefly

Have you ever mentored before?

Yes No

If yes, where?

Describe any leadership, coaching, teaching, or community experience

Why do you want to become a BIG CUZIN' mentor?

What life lessons or experiences could you share with youth?

How would you handle a youth who is disrespectful or resistant?

Have you ever been convicted of a crime? Sensitive

Yes No

If yes, explain briefly Sensitive

Type your full name to sign

Is there anything else you would like to add? (optional, 500 characters max)