Mentor Application

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This application will help Walk With Sally know more about you and your interests. In turn, this will help us best match your interests with a child (mentee). Once your Mentor Application is submitted, WWS Program Staff will be notified, and someone will reach out to discuss next steps. Thank you for your interest and we look forward to you joining the Walk With Sally team!

Personal Information

First Name

Last Name

Date

Street Address

City

Postal Code

State

Country

Home Phone

Work Phone

Cell Phone

What is your gender?

If not listed, please enter here:

Pronouns

Ethnicity

If Other, please enter Race/Ethnicity here

Date of Birth

How did you hear about Walk With Sally?

Current Employment History

Employer

Position Held

Street Address

City

State

Supervisor's Name

Supervisor's Title

Employment Start Date

Employment End Date

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Application Questions

Please answer all of the following questions as completely as possible.

General Questions:

Why do you want to become a mentor?

Please list the types of cancer that have impacted you.

Please describe your experience(s) with cancer and the age you were during that time. Who in your family has had cancer? What type of cancer did they have? How has it impacted you? Have you had cancer? Where are you in your recovery now? (Must be in remission for 5 years or more)

Do you have any previous experience volunteering or working with youth? If so, please specify.

What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain.

Can you commit to participate in the Walk With Sally mentoring program for a minimum of one year from the time you are matched with a youth?

How far are you willing to travel within Los Angeles while staying committed to the one year obligation? (Distance can be given in miles.)

Are you available to meet with a child six-eight hours per month and have contact at least once per week for one year? Please explain any particular scheduling issues.

Describe your general health. Are you currently under a physician's care or taking any medications? If so, please explain.

How would you describe yourself as a person?

How would your friends, family, and co-workers describe you?

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History & Background

Have you ever been arrested or convicted of a crime? If so, what were the circumstances?

Have you ever used illegal drugs? If so, what substances were used and how often?

Are you currently using any illegal drugs or controlled substances?

Do you drink alcoholic beverages? If so, what and how often?

Have you ever been convicted of a DUI, driving while under the influence of alcohol? If yes, when and what were the circumstances?

Have you ever received treatment for alcohol or substance abuse? If yes, please explain.

Have you ever been treated or hospitalized for a mental disorder? If yes, please explain.

Have you ever been investigated or convicted of child abuse or neglect? If yes, please explain.

Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? If yes, please explain.

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Information Release

Full Name

Date of Birth

Address

City

State

Postal Code

Current Driver's License No.

State

Attach your Driver's License and Car Insurance by simply take a photo and uploading the file. You are able to send us these documents at a later time if you'd like.

Driver's License

Car Insurance

Please list any other cities, states, and dates of residency during the past 10 years.

City

State

From (Month/Year)

To (Month/Year)

City

State

From (Month/Year)

To (Month/Year)

City

State

From (Month/Year)

To (Month/Year)

City

State

From (Month/Year)

To (Month/Year)

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Personal References

Please list the names, address, and phone numbers of four people you would like to use as character references (only people you have known for at least 2 years). Any Information Walk With Sally gathers from these references will be held as confidential and not release to you, the applicant.

Reference #1

Relationship

First Name

Last Name

How Long Known

Phone

Reference #2

Relationship

First Name

Last Name

How Long Known

Phone

Reference #3

Relationship

First Name

Last Name

How Long Known

Phone

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