Visionary Youth : Take Action : Barber & Stylist Mentoring

Our barbers are trained mentors, positive adult role models, and community champions.

When youth participate in the mentorship program, they will have the opportunity to:

• Build confidence and peer support toward individual and common goals.
• Build leadership, problem-solving, and social skills.

• Celebrate and be celebrated for their achievements.
• And build networks of support that last.

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Name

First Name

Last Name

Place Of Business (Required)

phone (Required)

address

Country

Address Line 1

City

State

Postal Code

Email (Required)

Gender

Female
Male

Date of Birth

Work

I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.
I understand that Visionary Youth Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.
I agree to allow Visionary Youth Mentoring Program to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.

I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed: • Copy of your valid driver's license and proof of auto insurance • Information Release Form • Interest Survey Form • DMV Release Form (state agency form) • Criminal History Release Form (state agency form) • Child Abuse and Neglect Release Form (state agency form) • Sexual Offender Release Form (state agency form)

Signature (Required)

By signing below, I attest to the truthfulness of all information listed on this application and agree to all of the above terms and conditions:

Date (Required)

Employment History (Required)

Employment History