VOLUNTEER IN PROBATION Perrysburg Municipal Court 300 Walnut Street, Perrysburg, Ohio 43551-1455 (419) 872-7925 VOLUNTEER MENTOR APPLICATION (Please Print ory Tpe Clearly and Fully Complete Both Sides) Date: ________________ VIP Office Use Only Mentor I.D.#: __________ Personal Information Name: __________________________________________________________________________________________ (FIRST) (MI) (LAST) Address: ________________________________________________________________________________________ (STREET) (CITY) (STATE) (ZIP) Home Phone: _________________________ Work Phone: _________________________ Ext.: ________________ (AREA CODE) (NUMBER) (AREA CODE) (NUMBER) Pager: ______________________ Other: ______________________ Other Phone Is: _________________________ (AREA CODE) (NUMBER) (AREA CODE) (NUMBER) (DESCRIBE CELL, ETC) Social Security #: ______________________ Gender: M F Date of Birth: ____/____/____ Age: ________ Current Marital Status: (Choose ONE Only) Employment Status: (Choose ONE Only) Married Widowed Unemployed Retired Separated Never Married Employed Full Time Student Divorced Employed Part Time Your Current or Immediate Past Employment: (Choose ONE Only) Managerial/Professional (teacher, doctor, social worker) Law Enforcement/Justice Technical/Sales/Administrative Religious Military Other _______________________________________ (please sp ecify) Current Employer Information: Employer Name: __________________________________________________________________________________ Employer Address,t Ciy, Zip __________________________________________________________________________ Your Job or Position ________________________________________________________________________________ Available to volunteer (days/rhous per week) ____________________________________________________________ Education: Primary Reason for Becoming a Mentor: What is highest level of education completed? (Choose ONE Only) Want to Give Back to the Community High School Diploma BA/BS Degree High School Diploma Masters Degree Had a Positive Experience with a Mentor as a Child College Courses Ph.D. Organization Sponsored Community Service Project Want Experience for Career or Educational Development Associates Degree Other _____________ (please specify) Other ___________________________________________ (please specify) (CONTINUED ON REVERSE SIDE) American LegalNet, Inc. www.USCourtForms.com >>>> 2 Drivers License/Auto Insurer D/L #: ______________________________________ Ins. Policy #: _______________________________________ Ins. Company Name: ______________________________________ Ins. Expiration Date: ______________________ Note: VIP is required to keep a photocopy of your drivers license and proof of insurance. Please have these available at your volunteer interview. Emergency Notification Name: ___________________________________________________________________________________________ (FIRST) (LAST) (RELATIONSHIP) Home Phone: ___________________________ Work Phone: ___________________________ Ext.: ____________ References Please list three (3) character references: one blood relative, one friend (2+ years), and one work related. Name: ___________________________________________________________________________________________ (FULL NAME OF RELATIVE) (PHONE) (OCCUPATION) ________________________________________________________________________________________________________________________ (STREET ADDRESS) (CITY) (STATE) (ZIP) Name: ___________________________________________________________________________________________ (FULL NAME OF FRIEND) (PHONE) (OCCUPATION) ________________________________________________________________________________________________________________________ (STREET ADDRESS) (CITY) (STATE) (ZIP) Name: ___________________________________________________________________________________________ (FULL NAME OF CO-WORKER) (PHONE) (OCCUPATION) ________________________________________________________________________________________________________________________ (STREET ADDRESS) (CITY) (STATE) (ZIP) Health & Activities Have you been treated for, or do you have, any health problems, physical or emotional, that could affect your activities with a mentee? Yes No If yes, please explain: ____________________________________________________ ________________________________________________________________________________________________ Have you ever done previous volunteer work? Yes No If yes, please describe work: ______________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Please list any clubs, organizations, religious congregations, and other groups that you belong to: ________________________________________________________________________________________________ Justice System History Have you ever been convicted of a misdemeanor or felony? Yes No Do you have pending a misdemeanor or felony case(s)? Yes No VIP policy disqualifies individuals who have been convicted of an offense. VIP policy temporarily disqualifies individuals tha t have a pending charge. I certify that the above information is complete and true. I understand that references will be contacted and a criminal recor ds check will be processed. I understand that VIP Mentoring Program is not obligated to assign me if, in their professional judgment, it would not be in my b est interest or in the best interest of the probationers served by the program. DATE ____________________ SIGNATURE _________________________________________________________ Please return to the address on the front of this application. American LegalNet, Inc. www.USCourtForms.com