Applications

APPLICATIONS

Kinship Adult Application Form

Name

First Middle Last

County of residence

Address

Street Address Address Line 2 City State ZIP Code

Phone

Applicant date of birth

Month

Day

Year

Employer Company Name

Employer company phone number

Please enter company's main phone number

Gender

Race/Ethnicity

Best times to contact you

8 AM - 3 PM

3 PM - 6 PM

6 PM- 10 PM

10 PM - 8 AM

How much time do you plan to commit to this program?

6 Months

1 Year

Roughly estimated, how many hours per month do you plan to spend with your youth partner?

What age group would you be interested in considering?

6-9 Years

10-12 Years

13 or higher

Any age

Why did you pick that age group?

Significant other's name

First Last

This is the start of the references section

Please list three references that we may contact who have known you for at least one year and may have observed you interacting or working with children. (Volunteer supervisor, employer, friend).

Reference 1 Name

First Last

Reference 1 Phone

Reference 1 Address

Street Address Address Line 2 City State ZIP Code

Reference 1 Relationship to you

Reference 2 Name

First Last

Reference 2 Phone

Reference 2 Address

Street Address Address Line 2 City State ZIP Code

Reference 2 Relationship to you

Reference 3 Name

First Last

Reference 3 Phone

Reference 3 Address

Street Address Address Line 2 City State ZIP Code

Reference 3 Relationship to you

Vehicle information and auto insurance

I understand that if I am accepted as a Kinship mentor, I will be transporting a youth or others in my car. I agree that I will maintain liability and no fault insurance on my vehicle pursuant to the statutory requirements of the State of Minnesota. Please provide the following information.

Do you have a valid Minnesota driver's license

Yes

If not, state of valid license you do hold.

Write the full state name.

Driver's license Number

Year

Make

Model

Color

License plate number

Insurance company

Enter name of your vehicle insurance company.

Policy number

Enter the policy number for your vehicle insurance.

Insurance company's address

Street Address Address Line 2 City State ZIP Code

Insurance agent's name

First Last

Insurance agent's phone number

How did you hear about our mentor program?

Brochure

Website

Friend

Church bulletin

Newspaper

Facebook

Why do you want to become a mentor to a child?

Friendship

Support

Resource

Advocate

Summarize your skills, qualifications, and experiences which you feel would be beneficial to our program:

Work with children

Empathy

Technology

Team building

Listening

List your major interests, hobbies, and recreational activities:

Sports

Gardening

Outdoor activities

Hiking

Video games

Board games

Fishing

Arts/Crafts

Swimming

Biking

In what activities (church, community, etc.) do you participate, or have you participated?

Church

Service Clubs

Recreation Clubs

School

Other relevant volunteer experience?

Can leave blank.

Are you under treatment for any medical/disability/mental health problems that would be a concern in this relationship?

Yes

Any major illnesses in the past 5 years?

Yes

What child behaviors would you not be able to tolerate?

Violent outbursts

Disrespect

Not following the rules

Whose rules of behavior should you follow?

Your own

Child's

Parent's

Program's

Have you ever been convicted of a felony?

Yes

Has your significant other been convicted of a felony?

Yes

Are you currently on probation?

Yes

In general, what does confidentiality mean to you?

Keeping things private

Sharing with spouse/others

Telling parent what child said

How important is confidentiality in this type of adult/child relationship?

Very

Not very

How would you deal with inquiries from schools, family court, case workers, parents, or others about the child you are mentoring?

Refer to Pro Kinship Director

Say nothing

Tell them what they want to know

What would you do if a child started talking about suicide, doing drugs, or other risky behaviors?

Talk to Pro Kinship Director

Ask more questions to the child

Talk to a parent

Parent Approval Form

What Mentor services are you interested in?

Mentor Wanted

Group Mentor

Both

Child Applicant Name

First Middle Last

Child Applicant Date of Birth

Month

Day

Year

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone

Contact of Primary Phone Number

i.e. Mom, Dad, Grandma, Grandpa

Secondary Phone

Contact of Secondary Phone Number

i.e. Mom, Dad, Grandma, Grandpa

Email of Applicant

Name of School that Child Attends

What grade is the child in?

Enter a number.

Mother's Name

First Last

Mother's Employer

Father's Name

First Last

Father's Employer

Child's Gender

Child's Race/Ethnicity

Type of Family?

Single Parent

Married

Blended

Other

Combined Annual Family Income Ranges:

$0 - $9,999

$10,000 - $24,999

$25,000 - $39,999

$40,000 - $59,999

$60,000 - $74,999

$75,000 - $99,999

$100,000 - more

Other children or family members living in the house:

Yes

Person 1 Name

First Last

Person 1 relationship to you

Person 1 Date of Birth

MM slash DD slash YYYY

Person 2 Name

First Last

Person 2 relationship to you

Person 2 Date of Birth

MM slash DD slash YYYY

Person 3 Name

First Last

Person 3 relationship to you

Person 3 Date of Birth

MM slash DD slash YYYY

Person 4 Name

First Last

Person 4 relationship to you

Person 4 Date of Birth

MM slash DD slash YYYY

How was your child referred to Pro Kinship?

Self

Church

Therapist

Teacher

Social Worker

School Counselor

Other

Who referred you?

First Last

How would this program benefit your child?

Support

Someone to hang out with

Confidant

Part of the family

Someone to rely on

What do you expect from the mentor?

Time

Support

Friendship for Child

Reliability

Consistency

Honesty

Confidentiality

How will it affect your other children if this child has a mentor friend?

No affect

Jealous

Happy for them

want a mentor of their own

Supportive

How will your child feel about having a Pro Kinship mentor?

Excited

Nervous

Uneasy

Joyful

Happy

Sad

Uncertain

Briefly describe you child's relationship with you at present.

Steady

Uncertain

Broken

Loving

Hurtful

Shaky

Rocky

Strong

Caring

Is there another parent visiting who shows interest in the child?

Yes

Please describe your child's relationship with his/her other parent?

Steady

Uncertain

Broken

Loving

Hurtful

Shaky

Rocky

Strong

Caring

Doesn't exist

Which of the following would interest you child?

Couple (may or may not have children)

Individual volunteer

Family

Are there any specific things that your child can't be involved in because of health or religious reasons, etc?

Yes

Learning disabilities?

Yes

Health Issues?

Yes

Physical Disabilities?

Yes

Is your child on any medication that would restrict his/her activity?

Yes

How does your child feel about school?

Excited

Does well

Lonely

Hates it

It is tough

Tolerates it

Bullied

Wants to be there

Gets along with others

Shy

What are your child's outstanding points?

Friendly

Goes with the flow

Helpful

Talkative

Happy

Smiley

Busy

Caring

Outgoing

Loving

What are your child's weaknesses?

Shy

Non-compliant

Quiet

Angry

Scared

Disrespectful

Unsure

Uneasy

Youth Registration Form

Child applying to the program, please fill out

What do you like to do for fun? (check all the apply)

Reading

Watch TV

Outside activities

Sports

Music

Dance

Gymnastics

Video games

Board games/toys

Arts/crafts

Describe yourself (your looks and personality) (check all that apply)

Cheerful

Shy

Outgoing

Sad

Quiet

Smiley

Loving

Caring

Friendly

Bully

Cute

Average

Strong

Leader

Follower

Agile

Brave

Fast

How important is personal hygiene to you?

Very important

Important

Not important

How do you feel about having a PRO KINSHIP mentor? (check all that apply)

Excited

Nervous

Uneasy

Joyful

Happy

Sad

Uncertain