The Community Outreach

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Applicant's Basic Information
* First Name
Middle Name
* Last Name
Home Address 1
Home Address 2
Home City
Home State
Home Zip code
Date of Birth
Primary phone
Other Phone
Email address
PasswordThe password you set here will be used to login and record interactions with your Mentees once you are approved for TCO and matched.
Confirm Password
Do you belong to a Church Community?
If yes, which one?
Who referred you to be a mentor?
Why would you like to be involved in this organization?
Convicted of a Crime?
If yes, please explain.
EducationLocationYears CompletedSpecialization
High School
Additional Courses
Describe any specialized training or skills that may be helpful to the ministry.
Please select any languages you may speak.
What is your race?
Employers are not contacted without your permission. This information assists us in funding and communications through our Sioux Empire United Way Grant process. If you are retired, please list most recent employer.

Employer Name
Employer Phone
Employer Address
Length in Current Position
To ensure quality programing, our Genesis Mentors are asked to provide three personal references.

Reference 1
Reference 2
Reference 3

I give my permission for The Community Outreach to contact references for the purposes of screening Genesis Mentors. This information contained in this application is true and correct. I understand that any omission or misstatement may be cause for exclusion from the Genesis Program or any other Program managed by this Ministry. I understand that the Ministry screens all volunteers through the National Sex Offender Registry and if I am on this registry, I will be disqualified as a Mentor. Believing that The Community Outreach is in need of my services as a volunteer I agree to perform my volunteer duties to the best of my ability, to hold absolutely confidential all information about the ministry, its clients, employees, volunteers, or donors that I may obtain, to adhere to the volunteer guidelines, and to meet my commitments or provide adequate notice so prior arrangements can be made.

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