ClockWise Connection Mentor Application
Sign in to Google to save your progress. Learn more
Legal Name *
First and last name
Chosen Name
Pronouns *
Email *
Phone number *
Home Address *
Gender Identity *
Date of Birth *
MM
/
DD
/
YYYY
Marital Status *
Race/Ethnic Identification *
Highest level of Education *
Employment Status *
Employer & Position Held? *
What social media platforms do you utilize? (check all that apply) *
Required
T-shirt Size *
How did you hear about ClockWise Connection?
Clear selection
Do you have any experience (formally or informally) mentoring youth? *
Do you have any training to be equipped to mentor youth?  (Check all that apply) *
Required
Do you speak any language other than English? *
Are you a member of a local church? *
Have you ever been arrested or convicted of a crime? *
Have you ever been convicted of a DUI or DWI? *
Have you ever been convicted of child abuse or neglect? *
Have you ever been investigated/convicted of sexual abuse or molestation? *
Have you ever received treatment for alcohol and/or substance abuse? *
Have you ever been hospitalized for a mental illness/disorder? *
What is your age preference of a potential mentee? Please check all that apply. *
Required
How many mentees are you comfortable with having? *
Required
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Clock, Inc. Report Abuse
Google Forms