Please answer all of the following questions as completely as possible.
1. Why do you want to become a Mentor? *
2. Do you have any previous experience Mentoring or working with youth? If so, please specify. *
3. What qualities, skills, or other attributes do you feel you have that would benefit a young person? Please explain. *
4. Can you commit to participate in the Community Pillars Mentorship Programme for a minimum of nine (9) months from the time you are matched with a young person? *
5. Are you available to meet with your mentee four hours per month and have contact at least once per week? Please explain any particular scheduling issues. *
6. Describe your general health. Are you currently under a physician’s care or taking any medications? Yes No If so, please explain. *
7. How would you describe yourself as a person? *
8. How would your friends, family, and co-workers describe you? *
9. Have you ever been arrested or convicted of a crime? If so, what were the circumstances? *
10. Have you ever used illegal drugs? Yes No If so, what substances were used and how often? *
11. Are you currently using any illegal drugs or controlled substances? Yes No If so, what substances are used and how often? *
12. Do you drink alcoholic beverages? Yes No If so, what and how often? *
13. Have you ever been convicted of driving while under the influence of alcohol? Yes No If yes, when and what were the circumstances? *
14. Do you use tobacco products? Yes No If so, what and how often? *
15. Have you ever received treatment for alcohol or substance abuse? Yes No If yes, please explain. *
16. Have you ever been treated or hospitalized for a mental disorder? Yes No If yes, please explain. *
17. Have you ever been investigated or convicted of child abuse or neglect? Yes No If yes, please explain. *
18. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? Yes No If yes, please explain. *
19. Are you willing to communicate regularly and openly with program staff, provide monthly information regarding your Mentoring activities, and receive feedback regarding any difficulties during your participation in the Mentoring program? *
20. Are you willing to attend an initial Mentor training session and in-service training sessions after being matched? *
Please read this carefully before signing: Community Pillars Mentorship Programme appreciates your interest in becoming a Mentor.
Please initial each of the following:
I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed:
Copy of your valid driver’s license and proof of auto insurance Information Release Form Personal References Form Interest Survey Form Certificate of Character br>
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
Please return or email this application and the items listed above to the Barbados Probation Department #33 Roebuck Street, Bridgetown. Email – probation.department@barbados.gov.bb
