Welcome Back Tarrant County

Mentor Application
Cornerstone Network Assistance

Mentor Name:
First M.I Last

Address:
Street City State Zip Code

Phone: ( ) ( ) ( )
Home Work Cell

Email:

Driver’s License Number: State Issued:

Gender: Male/Female ……… Marital Status: Single Married Divorced Separated Widowed

Hours Available per Week (circle): 3 4 5 6 Hours per Month: 12 16 20 24

Ethnicity: What Language Do You Speak: Eng., Spanish. Other

Church/Organization Affiliation:

Church/Organization Address:
StreetCityStateZip Code

Church/Organization Phone#: ( )

Have you ever been charged with or convicted of a misdemeanor or felony (other than traffic
violation)? Yes No

If so, briefly explain charge(s).

Briefly explain why are you interested in being a mentor?

Weclome Back Tarrant County Mentor application (cont.) 2009

Do you attend services regularly? Yes No Please share with us what church activities you are

actively involved in?

Does your church have a Prison Ministry? If not, how will your church support your mentoring

efforts?

Can you commit to at least three (3) hours per week to your mentoree for at least one (1) year?

Yes No

Does your family support your mentoring? Yes No

Are you continuing to grow in your Christian walk? Yes No

Are you willing to provide references for your mentoree? Yes No

What mentoring or prison ministry experience do you currently have?

Have you completed your mentor training? Yes No If so, please provide type(s) of training and

date(s) completed: Training Date Completed

Have you completed the TDJC three (3) hour training course? Yes No

Welcome Back Tarrant County Mentor Application | Confidential

Weclome Back Tarrant County Mentor application (cont.) 2009

Are you an ex-felon? Yes No If yes, please provide facility information:

Prison Name & Location Dates

Are you currently on parole or probation? Yes No

If yes, please provide your Parole Officer’s name:

When does your parole end?

Please share any hobbies or other skills you have?

I understand that the information given by me in this application will be verified and that
any false or omission of facts associated with this application may result in either denial
of mentoring or dismissal from the Welcome Back Tarrant County Mentor Program.

I certify that the answers and statements given by me on this application are complete
and true to the best of my knowledge and credence.

Signature Date:

Welcome Back Tarrant County Mentor Application | Confidential