LifeWorksMentoring.org

Peer Mentor Application for LifeWorks Mentoring

Please take the time to answer each question, all are required.

Personal Information

Name:
	(Last)	(First)	(MI)

Address:
	(Address)	(City)	(State)	(Zip)

Home Phone:

Cell Phone:

E-Mail Address:

Race/Ethnicity:

Age:

Sexual Orientation:

Gender Identity:

Languages Spoken:

Highest Education Level Completed:

Referred by:

Other interests that will be helpful for LifeWorks Staff to know about:

Employment

Employer:

Occupation:

Business Phone:

May we contact you at work? Yes No

Mentoring Questions

The following information is required:

1. What is Mentoring to you?

2. What qualities do you possess that will help you to support other LGBTQ youth?

3. What does Active Listening mean to you?

4. Explain what “boundaries” mean to you?

5. Have you ever participated in a group or team activity?

6. What do you think are three of the biggest issues facing Lesbian, Gay, Bisexual and Transgender (LGBT) youth?

7. Have you ever been in a mentoring relationship?

8. Do you have any medical or mental health requirements that would need to be accommodated?

9. Why do want to be a Peer Mentor and what do you hope to gain from the experience?

10. Can you be available on Wednesday evenings and occasional weekends to attend activities?

Click "Submit Information" below, and we will be in touch with you soon about setting up an interview.

If you have further questions about the Peer Mentoring Program please contact Daniel Dumont, Program Manager at ddumont@lifeworksmentoring.org

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