2014-15 Take Stock in Children (TSIC) Mentor Application Thank you for wanting to be part of the TSIC mentoring program! This is a two part application, one required by the Polk County School Board, and one required by the state agency of TSIC. There is a $25.00 application fee to cover the cost of a FDLE background check. If you cannot afford the processing fee, please call Shonia Bailey in the TSIC office at 863 519 8077 for possible financial assistance, or with application questions. Please send this application and payment (money order made out to Polk County School Board) to Polk Education Foundation, 1530 Shumate Drive, Bartow, FL 33830, attention: Shonia Bailey. ***If you are already an approved Polk County School Board volunteer only fill out the Take Stock in Children Application noting your current volunteer number and send in without payment. ***Teachers, just put your name and SAP number at the top of the PCSB Application, as your background check is on file, complete the TSIC application, and no payment is needed. Thank you!
POLK COUNTY PUBLIC SCHOOLS 2014-2015 VOLUNTEER APPLICATION In order to apply, you will need to: 1. Confirm with the school that you are not already an approved volunteer. 2. Review the qualifications carefully and sign the application. 3. Obtain a money orderr payable to the Polk County School Board in the amount of $25.00 to cover the Florida Department of Law Enforcement background check required for all applicants. 4. Bring completed application and payment to the school (please allow 2 to 3 weeks to complete the application process). *Required Information *Last Name: *First Name: M.I. Social Security Number - - *Date of Birth _/_/ No SSN *Gender: *Race: Home Phone: (_) -_ Business Phone: (_) - *Address: *City: *State: _ *Zip: List the schools where you will volunteer *School: School: _ School: _ Department of Public Relations & Strategic Partnerships 863.534.0636 Page 1 of 2
QUALIFICATIONS All volunteer applicants will be required to undergo a level 1 criminal background screening by the Florida Department of Law Enforcement. WILL NOT BE ELIGIBLE TO VOLUNTEER if person who has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to any offense constituting a felony under Florida law or the jurisdiction in which the offense occurred, as specifically set forth in Florida Statutes (FSS) 435.04 and Chapter 1012. To include but not limited to: *Battery, robbery or other felonies involving violence *Kidnapping of a minor *Burglary *Obscenity or pornography *Child neglect/abuse *Possession of concealed firearms or weapons * Domestic violence * Sexual misconduct *Drug related convictions *Sex offenses such as sexual battery WILL NOT BE ELIGIBLE TO VOLUNTEER if person who has been found guilty of any misdemeanor offense prohibited under: *Florida Statute 784.03 relating to battery AND *Florida Statute 787.025, relating to luring or enticing a child MAY BE CONSIDERED if conviction or judicial action is more than 5 years old and the offense is not specified in or subject to: *Florida Statute 784.03 relating to battery AND *Florida Statute 787.025, relating to luring or enticing a child I specifically authorize the release of my confidential criminal history to Polk County School Board pursuant to The national Child Protection Act and F.S. 943.0542 Volunteers may challenge the record only as provided in F.S. 943.056. I affirm that my responses are true, complete and correct to the best of my knowledge and are made in good faith. I agree to abide by the rules and regulations of the volunteer program. I understand that all involvement with students is restricted to approved school activities. I acknowledge that I have read the qualifications provided. *Signature: Date: The School Board of Polk County, Florida, prohibits any and all forms of discrimination and harassment based on race, color, sex, religion, national origin, marital status, age, homelessness, or disability or other basis prohibited by law in any of its programs, services, activities, or employment. To file your concerns, you may contact the Office of Equity & Compliance in the Human Resource Service Division at (863)534-0513 Page 2 of 2
Information required by the TSIC state agency Identifying Information: Name: Polk County School Board Volunteer # Date of Birth: Home address: Home phone: _ Mobile phone: Polk County School Board Volunteer # (if you are already approved)_ School you are requesting: E-mail address: Place of Employment: Title: Employment Start Date: Background Information Ethnic Group: (check one) Caucasian African American Hispanic Asian American Indian Other (please specify) _ Age Category: (check one) 18-30 31-40 41-50 51-60 61+ Are you married? _ Do you have children? # sons _ age(s) # daughters _ age(s) When you were a teenager, to what income group did your family belong? low income middle income high income Career/Education Information Highest education completed: some school, not a high school graduate GED high school graduate associate s degree in from technical/vocational certificate in from _ bachelor s degree in from master s degree in from doctorate in from other
If yes, please specify: List any clubs or organizations of which you are currently a member: Mentor Information How would you describe your communication style? friendly and outgoing usually wait to be approached by someone new reserved until I get to know someone new I am interested in becoming a mentor because: (check all that apply) I think I d be a positive role model I like children I have the time to give I overcame difficulties growing up and would like to help someone else I think I have the personality and abilities to be a good mentor I am interested in making a difference in the life of a child I believe in the value of mentoring I wish I had had a mentor when I was a teenager Do you have any specific training or experience in dealing with any of the following youth issues: (check all that apply, and if yes, please explain) drug awareness teen pregnancy teen violence sex/abstinence other Please indicate how comfortable you would be in talking to a protégé about the following: very comfortable comfortable somewhat not at all world of work goal setting career planning college planning personal experiences hobbies/interests personal problems drug awareness sex/abstinence
Please indicate how comfortable you would be in handling the following potential problems: (vc = very comfortable; c = comfortable; s = somewhat comfortable; n = not comfortable) _ you have a hard time reaching your protégé _ you make arrangements to meet, and your protégé doesn t show _ your protégé seems unresponsive to your interest in getting to know him/her _ your protégé calls you too often _ your protégé asks you for money _ your protégé has little interest in your job/profession _ your protégé shares very sensitive thoughts or information with you Are there any particular problems you would prefer not to handle as a mentor? Is there anything else you would like us to know about you? If yes, please explain: The undersigned acknowledges and agrees that 1) he or she is not obligated, if called upon, to perform the volunteer services herein applied for; 2) Take Stock in Children is not obligated to assign or actively seek to assign her or him a Take Stock in Children student; 3) as part of the Take Stock in Children matching process, additional information may be requested from the applicant, and 4) Take Stock in Children reserves the right at all times to terminate any match between any volunteer mentor and student for whatever cause. I declare that all of the statements made in this application are true, complete and correct to the best of my knowledge. Applicant s Signature Date As a mentor in the Take Stock in Children program, I will always act in a behavior that is in the best interest of my student. Accordingly, I pledge to each of the following volunteer policy statements. Please initial your approval next to each statement. I will notify Take Stock in Children if I must terminate my mentor position for any reason. I will notify my student or his or her school liaison or the Take Stock in Children Student Advocate if I am unable to attend a previously scheduled meeting. I will not willfully arrange contact with my student off school property and not under the supervision of Take Stock in Children or school officials. I will not drive my student in my car. I understand that Take Stock in Children will terminate my relationship with my student if I violate any of the above policies. I will adhere to the volunteer policies of my local school district.
REFERENCES: Please print COMPLETE name, address, and relationship of three people. They must have known you for at lease 2 years. Each should be in a position to evaluate your qualifications as a mentor. Please do not include family members, current boyfriends, girlfriends, or fiancées as references. Name Address Zip Code Phone # 1. ()_ Relationship Years Known _ 2. () Relationship Years Known 3 () Relationship Years Known If you are currently employed, please print the name and address of your work supervisor. If employed less than 6 months, the previous employer. 4. () Name Address Zip Code Phone # Liability Release/Consent for Release of Information I do hereby affirm the above information is true. I understand if denied acceptance into a mentoring program, no reason for denial will be given. I hereby consent to (local program) to release information to other entities, agencies, or individuals. I hereby release Take Stock in Children from any liability whatsoever for any information released or any acts or omissions connected with this application. I understand and consent to Take Stock in Children examining any and all available records or information from any source, to include but not be limited to criminal records. I hereby allow Take Stock in Children to release any information compiled from my interview, references, or other sources pertaining to my application to become a mentor to Take Stock in Children. Take Stock in Children will use this information for the purpose of evaluating my ability to meet the initial criteria to serve as a mentor with a mentoring agency. I hereby release Take Stock in Children from any liability, debt, claim, suit, or obligation of any nature whatsoever should any information be obtained by any other individual, party, or entity of any nature whatsoever. Signature Date Please print your name here. Polk County Take Stock in Children