Mentor Application

General Information

Which Village location are you applying to serve as a mentor?

The Village Anderson The Village Noblesville

What program are you applying for as a mentor or volunteer?

Boys H.U.T.S (6th-12th) Girls H.U.T.S (6th-12th)

Have you attended a HUTS group session?

Yes No

How did you learn about The Village Indiana?

Mentor Information

Title

Name

Preferred Name

Birth Date

This address will receive a confirmation email

Phone (ex. 555-555-5555)

Phone Type

Mobile Work Home

Address

Employer

Occupation

Work Address

May we contact you at work? Yes No

If yes, work phone number

Ethnicity

Black or African American White or Caucasian Hispanic Asian Native Hawaiian/Pacific Islander Native American or Alaskan Native

What languages are you comfortable speaking?

English Spanish Other (please list below)

Shirt Size

Allergies or Other information

Application Questions

Briefly describe your motivation for applying to become a mentor/volunteer.

What, if any, other groups or organizations have you been involved with as a mentor/volunteer?

Do you believe in God or in the concept of a higher power? If so, describe the most useful and empowering aspects of your relationship with God. If not, what reference point do you use?

Have you ever been convicted of a crime?

No Yes

If yes, please explain (offense, date, location, circumstance, and outcome)

References

Please provide a minimum of three references who have known you for more than one year and preferably observed you with youth. Do not include more than one family member.

Reference #1

Name

Phone

Relationship

Reference #2

Name

Phone

Relationship

Reference #3

Name

Phone

Relationship

Emergency Contact

Name

Phone

Phone Type Mobile Work Home

Relationship

Waivers

Photo and Social Media Release

I agree to allow the mentoring program to use any photographic image of the mentee taken while participating in program activities. These images may be used in promotions or other related marketing materials for the program, including social media.

Yes No

Mentor Agreement

I understand that:

1. The references I listed will be contacted by mail, email, or telephone.

2. The information I provided will be used to conduct a background check, to include criminal background, sexual offender, and child abuse registry checks and other records where required by local, state, or federal law for certain individuals who may interact with participating minors.

3. The completion of this volunteer application does not obligate me to perform any volunteer services.

4. The mentoring program is not obligated to match me with a youth.

5. The mentoring program is not obligated to provide a reason for its decision in accepting or rejecting my application to be a mentor.

6. Other youth organizations where I have worked or volunteered may be contacted as references.

7. As part of the enrollment process, I may be asked to provide additional personal information prior to any recommendations for assignment (such as social security number, valid driver’s license or ID, fingerprints, or proof of auto insurance), if requested.

8. I am required to follow all mentoring program guidelines and policies and understand that any violation will result in suspension and/or termination of the mentoring relationship.

By typing my name below, I am agreeing to all the statements above and certify that all elements of the personal data I have provided are true, accurate, and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it or in any interviews will be sufficient grounds for rejection for consideration as a volunteer. PLEASE TYPE YOUR NAME BELOW signifying an e-signature.

Mentor Application

Description

Please Fix the Following