Youth Mentor Application - National Alopecia Areata Foundation

Name*

First Last

Email*

Address*

Street Address City State ZIP Code

Mobile Phone*

Home Phone

Date of Birth*

Gender*

Type Of Alopecia

Languages Spoken*

Separate by commas.

School Name

Grade Level

Extracurricular Activities

Have you worked with children before? Please explain.

How long have you been involved with NAAF and what NAAF activities have you been a part of?

Do you have transportation?

How many hours per month are you able to mentor?

Have you ever been arrested or involved with the courts? If yes, please explain.

EMERGENCY CONTACT INFORMATION

In case of emergency, please contact the following person.

Contact Name*

Contact Phone*

Reference 1

Name

First Last

Phone

Email

Relationship

Years known

Reference 2

Name

First Last

Phone

Email

Relationship

Years known

Reference 3

Name

First Last

Phone

Email

Relationship

Years known

YOUR APPLICATION IS NOT COMPLETE, PLEASE CONSENT TO THE AGREEMENT BELOW AND CLICK SUBMIT

As a site-based Mentor, I agree to the following basic requirements:

To attend an approved training session before beginning to mentor.
To talk to or meet with my mentee for at least four hours each month for the year
To be on time for my scheduled mentoring sessions.
To notify the mentee and his/her parent, if I am unable to attend my scheduled mentoring session.
To engage in the mentoring relationship with an open mind.
To ask for help and accept assistance from the mentor coordinators when necessary.
To keep discussions with my mentee confidential except where his/her safety and/or welfare may be in jeopardy.
To notify program personnel and the mentor coordinator of any changes in my employment, address, and/or telephone numbers.
To notify the mentor coordinator if I wish to change my assigned mentee.
To participate in the end-of-year evaluation process.
To notify program personnel and the mentor coordinator if I no longer wish to mentor.
To meet with my mentee only with permission of his/her parents’ and a written agreement/ permission form.
Submit the Verified Volunteers background check.
Provide feedback to NAAF on a quarterly basis through survey completion.
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We appreciate your interest in becoming a mentor to a child and/or their parent(s). By submitting this application, you agree to the terms of the mentor agreement and attest to the truthfulness of all information listed on this application.

Name

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