Mentor Application (Type or print legibly)

Transcription

1 Mentor Application (Type or print legibly) Thank you for applying to be a mentor in the BGC/STEM Mentoring program! In order to ensure a safe environment for our youth, we run background checks on all staff and volunteers. Please complete this required information thoroughly and contact us with any questions. Date: Name of Applicant: Date of Birth: Home Address: City: State: ZIP: Home Telephone: Home Employer: Occupation: Business Address: City: State: ZIP: Business Telephone: Business Fax: Business Available days and times to mentor (Check all that apply) Monday Tuesday Wednesday Thursday Friday 3 4 pm 4 5 pm 5 6 pm 6 7 pm 7 8 pm Preferred days and times to mentor Choice #1: Choice #2: Choice #3: Do you prefer to be matched with a group of: (check one) Boys Girls Boys and Girls No Preference Write a brief statement on why you wish to be a mentor in the BGC/ STEM Mentoring program. (On a separate sheet of paper or back of application)

2 Describe special interests/hobbies which may be helpful in matching you with mentees (cooking, crafts, career interests, games, sports, computers, art, languages, music, etc.). (On a separate sheet of paper or back of application) List the addresses where you have lived for the last five years (begin with the most recent after the current address listed above): The address listed above has been my only residence for the past five years. Dates: Address: City: State: ZIP: Dates: Address: City: State: ZIP: Dates: Address: City: State: ZIP: Provide two personal references (other than family members): 1. Name: Telephone: Relationship: Home Address: _ City: State: ZIP: 2. Name: Telephone: Relationship: Home Address: _ City: State: ZIP:

3 Provide two professional references: 1. Name: Telephone: Relationship: Home Address: _ City: State: ZIP: 2. Name: Telephone: Relationship: Home Address: _ City: State: ZIP: EMPLOYMENT HISTORY List the last three places of employment with the most recent first: Company: Address: City: State: ZIP: Dates of Employment: to Title: Company: Address: City: State: ZIP: Dates of Employment: to Title: Company: Address: City: State: ZIP: Dates of Employment: to Title:

4 Mentor Release Statement I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of the BGC/STEM Mentoring program. I understand that the program involves spending a minimum of one hour/week at the assigned location. Further, I understand that I will attend a training session, and communicate with staff regularly. I am willing to commit to one year in the program and then may be asked to consider renewing for another year. I have not been convicted, within the past ten years, of any felony or misdemeanor classified as an offense against a person or family, of public indecency, or a violation involving a state or federally controlled substance. I am not under current indictment. Further, I hereby fully release, discharge and hold harmless the BGC/STEM Mentoring program, participating organizations and all of the foregoing employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs and expenses which may be or may at any time hereafter become attributable to my participation in the BGC/STEM Mentoring program. I understand that the Mentoring program staff reserves the right to terminate a mentor from the program. The program takes place within the confines of the program s policies and does not permit relationships established between mentor/mentee and family members beyond the organized and supervised activities of the program. I give permission for program staff to conduct a criminal background check as part of the screening for entrance into the program. This includes verification of personal and employment references as well as a federal criminal background check. Program staff has final right of acceptance of applicant into the program and reserves the right to terminate a mentor from the program at any time. I have read this Release Statement and agree to the contents. I certify that all statements in this application are true and accurate. Signature of applicant Date Print Name

5 Mentor Closure and Termination Agreement Mentoring program at the Boys & Girls Club of Newport County. I (Name of Mentor) have served as a Mentor to (Name of Mentee), currently age since (Month, Day, Year) in the Mentoring program at the Boys & Girls Club of Newport County. On (Date) I met with said Mentee, and program official(s) and agreed to terminate my relationship with said Mentee. As of (Date),I am no longer engaged as a Mentor in the BGC/STEM Mentoring program at the Boys & Girls Club of Newport County. I understand and consent that as of this date I am not permitted to engage in any activities or contact said Mentee (e.g., scheduled or unscheduled visits, activities, meetings in the community or beyond, public places, designated site, said Mentee s home or mine, or by any other means including via telephone, , text or social media) under the auspices and supervision of the STEM Mentoring program at the Boys & Girls Club of Newport County. Any such contact will be the full responsibility of the Mentor and Mentee. Further, I hereby fully release, discharge and hold harmless the BGC/STEM Mentoring program, participating organizations and all of the foregoing employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs and expenses which may be or may at any time hereafter become attributable to my participation in and termination from the BGC/STEM Mentoring program at the Boys & Girls Club of Newport County. I have read this Closure and Termination Agreement and fully agree to its contents. Signature of mentor Date Printed name of mentor

6 Additional Space for Application Responses