Mentor Application

First Name *

Last Name *

Date *

Best Phone: *

Alternate Phone:

Email: *

Your Church

Emergency Contact

First Name *

Last Name *

Phone: *

Email: *

Relationship: *

References and Ministry Experience

Please list three references. If applicable, include a pastor or someone in your church leadership.

First Name *

Last Name *

Phone *

Email *

First Name *

Last Name *

Phone *

Email *

First Name *

Last Name *

Phone *

Email *

Please list any ministry experience you have had (i.e., leadership, service roles, etc.) *

Please answer the following questions:

1. What interests you in becoming a mentor for one of the members of this program? *

2. Describe your perspective on how people become addicted to substances, and your perspective on how then people overcome addiction. *

3. Realizing that this is a distinctly Christian organization, do you feel that you would have any conflict with the mission's goals and objectives? Why or why not? *

4. List any goals you may have for this relationship and your plan of action to meet those goals. *

5. Please list your hobbies and skills. We will use this information to match you with a mentee that shares your interests or that could benefit from your gifts. *

6. How many mentees are you willing to mentor? *

7. What is your availability to be a mentor? (Days/Times) *

8. Please use this space to tell us anything else about yourself that you feel is important for us to know. *

Substance Abuse/Addiction:

A. Do you currently have or ever had challenges related to substance abuse/addiction? *

Yes

B. If yes, how long have you been substance free?

C. Briefly describe your addiction and the treatment program(s) that followed.

I have answered all the above questions honestly and to the best of my ability. I understand that the submission of this application does not guarentee admittance into the mentoring program. I will not begin mentoring until I have spoken to and received instruction from the mentor program coordinator.

I acknowledge that all approved mentors will be subject to a background check. I also understand that mentors who relapse will no longer be able to mentor clients.

I have read and understand the Statement of Faith that reflects the values of the Las Vegas Rescue Mission

Last Step!

How would you like us to contact you? *

Phone

I would like to receive email communications from the Mission with information about upcoming events and other ways I can help

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Mentor Application

Emergency Contact

References and Ministry Experience

Please answer the following questions:

Substance Abuse/Addiction:

Last Step!

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