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Mentor Application

Welcome

Contact Information

First Name *This question is required.

Middle Initial

Last Name *This question is required.

Have you gone by any other last names during the previous 7 years? *This question is required.

If you said yes, please list your previous last names

Gender *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Home Address *This question is required.

Apt/Suite

City *This question is required.

State *This question is required.

Zip *This question is required.

Have you lived outside of South Dakota in the past seven years? *This question is required.

Please list one mailing address for each state that you have lived in during the past seven years.

Email Address *This question is required. This question requires a valid email address.

Home Phone Number

Work Phone Number

Cell Phone Number

By opting in I agree to Lutheran Social Services South Dakota's terms and conditions and privacy policy.
I also consent to Lutheran Social Services South Dakota to send SMS related to my mentoring activities.
Message frequency varies for HELP text us at 605-496-0003 to unsubscribe text STOP standard messages and data rates my apply. *This question is required.

Best contact method

Email
Text
Cell Phone
Work Phone

Employment Information

Employer Name

Job Title

Work Address

City

State

Zip

Number of Years with Employer

Do you speak additional language(s)?

List language(s) spoken

Are you able to mentor at least one year? *This question is required.

Have you ever been convicted of a drug charge? *This question is required.

Drug Charge Information

Charge

Date This question requires a valid date format of MM/DD/YYYY.

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Have you ever been convicted of a criminal offense? *This question is required.

Criminal Offense Information

Charge

Date This question requires a valid date format of MM/DD/YYYY.

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Have you ever been convicted of abuse, neglect, or assault? *This question is required.

Offense Information

Charge

Date This question requires a valid date format of MM/DD/YYYY.

calendar