First Name *

Last Name *

Email *

Phone *

Race/Ethnicity *

Language Preference *

Gender *

Date of birth *

Yes, I would like to receive emails and texts about how COPE helps youth, including parent education and counseling options. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Address

City *

State *

Country *

Postal code *

We require that you have a valid driver's license and current auto insurance. Please upload both sides of your driver's license and a copy of your auto insurance, showing your coverage and that it's current.

File Upload of Driver's License *

File Upload for Auto Insurance *

Please provide three references. Only list references that you have known for at least one year.

Familial Reference-First Name *

Familial Reference-Last Name *

Familial Reference-Email *

Familial Reference-Phone *

Familial Reference-Relationship *

Familial Reference-Years Known *

Professional Reference-First Name *

Professional Reference-Last Name *

Professional Reference-Email *

Professional Reference-Phone *

Professional Reference-Relationship *

Professional Reference-Years Known *

Personal Reference-First Name *

Personal Reference-Last Name *

Personal Reference-Email *

Personal Reference-Phone *

Personal Reference-Relationship *

Personal Reference-Years Known *

Have you held a volunteer or paid position where you worked with children? (for example school employee, nannying, coaching, etc.) *

Yes

For Mentors in the Across Ages Program

I understand that:

The references and youth organizations that I have worked for, or been involved with as a volunteer, whose information I have provided may be contacted by telephone or email.
I am in no way obligated to perform any volunteer services.
The information I provide may be used to conduct a background check, to include a driving records check, criminal background check, and other records where required by local, state, or federal law for volunteers working with youth. If matched, the information I provided may also be used to conduct an annual criminal background and driving records check. Continued involvement will be based on the information discovered.
Background checks will be updated every 3 years while I am still matched with a youth.
As part of the enrollment process, I agree to provide additional personal information to assist COPE Family Support in making a recommendation for matching.

6. I will not transport my mentee in my personal vehicle at any point during this program.

I accept these terms and conditions:*

Signature of Mentor

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