Family Mentor Application

Thank you for your interest in the Family Mentor Program.

As a Mentor you will work to build a committed and trusting relationship with the parents to support them though this transition. A mentor will empower them to define and meet goals for themselves, to achieve self-reliance, and offer advice that parents may be uncomfortable seeking from elsewhere.

First Name *

Last Name *

Street Address *

Address Line / Community

City *

State *

Zip Code *

Which County would you like to volunteer in *

Lee

Charlotte

Both

Best Phone Number to Contact *

Email Address *

Company Name

Are you a full time resident? *

If seasonal, What dates are you here? *

Date of Birth MM/DD/YY *

Gender *

Languages you are fluent in:

Do you have special skills that you would like to tell us about?

On a scale of 1-5, (where 1 is extremely confident to assist and 5 is unable to assist) please tell us your ability to comfortably work with: *

	1	2	3	4	5
A family who suffers from substance abuse problems	1	2	3	4	5
Mental Health	1	2	3	4	5
Domestic Violence	1	2	3	4	5
Neglect	1	2	3	4	5
Poverty or difficult living conditions	1	2	3	4	5
Sexual Abuse	1	2	3	4	5

Training Availability? *

Report abuse

Your completed application form will be forwarded to Family Mentor Coordinator

Patrice Cunningham - Patrice@UnitedWayLee.org - 239.433.7557
United Way of Lee, Hendry, Glades, and Okeechobee

7273 Concourse Drive, Fort Myers, FL 33908

Volunteer Fair	HSIN Meeting	Kiwanis Presentation
Facebook/Twitter	Bill Board	Rotary Presentation
Flyer or posting	Cypress Lake Methodist Church	Current Mentor
United Way Website	Newspaper	Other Other