Mentor Application Form

Contact Information

Availability

WeekdaysWeeknightsWeekends

Preferred Contact Method: PhoneTextEmail

Your Background

1. Have you experienced any of the following? (Check all that apply) Recovery from addictionIncarcerationStreet life/homelessnessCourt or probation involvementOther

2. Briefly share your story and why you want to be a mentor

3. What life lessons or strengths do you want to pass onto someone else?

Mentor Role Commitment

Are you willing to: Commit to mentoring for at least 6 monthsMeet weekly (in person or virtually)Attend mentor check-ins or trainingsLead by example and communicate respectfullyYes, I understand the commitment and am ready to mentor.

Experience & Skills (Optional)

Do you have experience in group leadership, recovery coaching, teaching? YesNo

Are you CPR certified, a licensed counselor, peer support specialist, or other certified leader? YesNo

References (Optional but Encouraged)

Please list one or two people who can speak to your characterand reliability

Emergency Contact

Background Check

Are you willing to undergo a background check if needed? YesNo

(Note: We do not disqualify based on past records. This helps with participant safety and role placement.)

Anything Else You'd Like to Share?

Second Chance at Life

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FAQs

Ph. (309) 240-6065

dfeltz@secondchance-life.com

416 Main Street, Suite 601,
Peoria, IL 61602