be a part of our story

MENTOR APPLICATION:
Thank YOU for your interest in serving as a mentor to a young girl who has experienced the early loss of her mother.  Please complete the form below and we will be in touch with additional, more detailed information regarding next steps. 

PLEASE NOTE:  empowerHER conducts Mentor Interviews twice a year.  We will begin our Fall interviews September 1, 2018.  Rest assured, we are working tirelessly to serve the needs of all girls in need.  However, at this time we are in need of mentor applicants on Cape Cod and in Central Massachusetts and Metrowest areas.  

CONTACT INFORMATION
Cell Phone *
Cell Phone
Preferred form of contact: *
EMPLOYMENT INFORMATION
Work Phone *
Work Phone
TELL US MORE ABOUT YOU!
1. Please indicate an age preference you may have: *
4. Please initial by checkmark the two statements below: *
5. Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance? *
6. Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in question #5? *
8. Educational Background (check one): *
9. What is the best time for you to volunteer? (check all that apply) *
10. The girl I would prefer working with is: *
PERSONAL REFERENCE
Phone *
Phone
PROFESSIONAL REFERENCE
Phone *
Phone
PERMISSIONS & SIGNATURE
Date of Birth *
Date of Birth
I hereby grant permission for empowerHER to use my images on the empowerHER website or other official publications. *