MENTORING APPLICATION - House of Healing

Contact Information

Name

First Middle Last

Other names or maiden name

Phone (Home)

Phone (Cellphone)

Address

Street Address Address Line 2 City State ZIP Code

Email

Birthdate

Marital Status

Spouse's name

Children's names/ages?

Have you ever been convicted, received deferred adjudication, or pled no contest or nolo contendere for a criminal offense?

Yes
No

A “Yes” to any of these will not necessarily disqualify you from volunteering. Rather, House of Healing, Inc. will take various factors into consideration, such as the relation, if any, each offense bears to the position applied for, the date and severity of each offense, relevant facts and circumstances surrounding each offense, the outcome, and the applicant’s record since the time of the offense(s). A criminal background check will be run regardless of how you answer.

Explain below

Education

High School diploma

Yes
No

Number of years completed

School (GED)

Yes
No

College and/or Vocational School

School	Degree Earned	Dates

Describe other training or degrees

Previous Volunteer Experiences

List most recent volunteer experience first.

Organization

Address

Phone

Date of Employment, from

Supervisor’s Name

to

Position/ Duties

Add another Volunteer Experience

Yes
No

Organization

Address

Phone

Date of Employment, from

Supervisor’s Name

to

Position/ Duties

Add another Volunteer Experience

Yes
No

Organization

Address

Phone

Date of Employment, from

Supervisor’s Name

to

Position/ Duties

Employment History

List most recent employment first.

Employer

Address

Phone

Date of Employment, from

Supervisor’s Name

to

Position/ Duties

Add another Employment

Yes
No

Employer

Address

Phone

Date of Employment, from

Supervisor’s Name

to

Position/ Duties

Add another Employment

Yes
No

Employer

Address

Phone

Date of Employment, from

Supervisor’s Name

to

Position/ Duties

Additional Information

What is your reason for wanting to be a mentor at House of Healing, Inc.?

Do you consider yourself to be a Christian?

Yes
No

How long have you been a Christian?

As a Christian, what is the basis of your salvation? Can you explain your salvation experience?

Please provide the following information concerning your local church.

Church Name	Denomination	Address	Pastor’s Name	Positions which you have served

Please write a brief statement about how your faith would affect your volunteer work at House of Healing, Inc.

What special skills, talents, gifts or personality traits would you bring to House of Healing?

Have you attended Bible studies? If, so, which Bible studies have you completed?

What do you consider to be possible areas of weakness?

Are there any particular personality types with whom you have difficulty working with?

References

Please list persons who are not related to you and whom you have known for at least two (2) years. Please include their name, address, city and zip code, phone number, years you have know them, and what your relationship is to them.

Reference #1

Name

Phone

Address

Street Address City State ZIP Code

Email

Years known

Relationship

Reference #2

Name

Phone

Address

Street Address City State ZIP Code

Email

Years known

Relationship

Reference #3

Name

Phone

Address

Street Address City State ZIP Code

Email

Years known

Relationship

Reference #4

Name

Phone

Address

Street Address City State ZIP Code

Email

Years known

Relationship

Applicant’s Certification and Agreement

I certify that the facts set forth in this volunteer application are true and complete to the best of my knowledge, and I authorize House of Healing, Inc. to verify their accuracy and to obtain reference information concerning my character and capabilities. I release House of Healing, Inc. and any person or entity providing such reference information from any and all liability relating to the provision of such information or relating to any decision made based upon such information. If I become a volunteer at House of Healing, Inc. , I agree to fully adhere to its policies and rules, including those rules relating to maintaining client confidentiality. I recognize that, as a volunteer, I will serve in a different role than the employees of House of Healing, Inc., and I am not seeking nor expecting to receive any compensation or other benefits in return for any volunteer services which I may provide for House of Healing outside of what is outlined in the Mentoring Policies and Procedures handbook. I certify that I have read, and I am in full agreement of the Statement of Faith and Mission Statement of House of Healing, Inc.

YOUR NAME BELOW IS YOUR SIGNATURE OF AGREEMENT*

Date

Comments

This field is for validation purposes and should be left unchanged.

MENTORING

Apply to Volunteer

HOUSE OF HEALING MENTOR APPLICATION FORM

Contact Information

Education

Previous Volunteer Experiences

Employment History

Additional Information

References

Applicant’s Certification and Agreement