Mentor Application Form (Page)

SECTION ONE - PERSONAL INFORMATION

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Phone Type*

Home
Cell
Work

When is the best time to call?*

How Long Have You Lived in Florida?*

Email*

Email addresses allow us to contact the greatest number of people most efficiently at a minimal cost. Be assured that email addresses will be used for professional communications only.

Date of Birth*

Gender*

Marital Status

Do you have children? If yes, please indicate the number of daughters & sons, as well as their ages

Ethnic Group*

SECTION TWO - CURRENT EMPLOYMENT

Employment Status*

Employed (Please fill out employer below)
Unemployed
Retired

Employer*

Employer Address*

Street Address Address Line 2 City State ZIP Code

Employer Phone*

Your Title/Position

Department

SECTION THREE - SCHOOL PREFERENCE & AVAILABILITY

Check the area(s) you would like to mentor in.*

NORTH (Rivera Beach, PBG & Jupiter area)
CENTRAL (West Palm Beach to Lake Worth area)
SOUTH (Boynton Beach to Boca Raton area)
WEST (Wellington to Royal Palm Beach area)
Belle Glade and Pahokee area

List any specific schools you would like to be assigned to mentor at.

SECTION FOUR - EDUCATION

Highest Level of Education Achieved

If degree, which field?

Please indicate any other languages spoken

Please specify any volunteer experience or training you have had working with children in the past

SECTION FIVE - SKILLS/INTERESTS

Please check one or more ways you would be willing to volunteer.

Administrative
Donate Products/Services
School Supply Drive
Special Events
Other

If other, please specify how you would be willing to volunteer.

Please indicate any other skills you would like to share with our agency and/or students.

Do you have any specific training or experience in dealing with any of the following youth issues? (Check all that apply)

Drug Awareness
Teen Pregnancy
Teen Violence
Sex/Abstinence
Other

If you selected any of the boxes above, please explain.

Please list any clubs or professional organizations you are a member of

I am interested in becoming a mentor because (check all that apply):

I would be a positive role model
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

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

Is there anything else you would like us to know about you?

How did you hear about Take Stock in Children?*

SECTION SIX - BACKGROUND INFORMATION

In order for Take Stock in Children to complete the processing of mentor applications, it is our policy to have a routine local, state and federal criminal/predator background check conducted for all potential mentors. This background check will be conducted by the School District of Palm Beach County School Police. The results of the background check will remain confidential, and the property of Take Stock in Children and the Palm Beach County School District Police. (Per School Board Policy a background check will be required once a year before you can mentor.)

Do you have any objection to undergoing a background check in order to become a mentor?*

No
Yes

Do you have any felony charges? Convictions?*

No
Yes

Do you have any misdemeanor charges? Convictions?*

No
Yes

Would you have any objections to taking a drug test if necessary?*

No
Yes

If you answered yes to any of the questions above, please explain.

Personal References

Please provide the names, phone numbers, and complete mailing address of three people we can contact.

Personal Reference #1

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Relationship*

Years Known*

Personal Reference #2

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Relationship*

Years Known*

Personal Reference #3

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relationship

Years Known

SECTION SEVEN - LEGAL/RELEASES

PHOTO AND PRESS RELEASE*

I have read and agree to the Photo and Press Release.

I do hereby give Take Stock in Children Palm Beach County, their assigns, licenses and legal representatives the irrevocable right to use my name, picture, portrait, photograph, and visual likeness in all forms and media in all manners, including photo, film, audio and video representations, for nonprofit, public purposes, and I waive any right to inspect or approve the finished product that may be created in connection therewith.

Signature*

First Last

ACKNOWLEDGMENT*

I declare that all of the Statements made in this application are true, complete and correct to the best of my knowledge.

The undersigned acknowledges and agrees that 1) He/she is not obligated if called upon to perform the volunteer services herein applied for; that Take Stock in Children is not obligated to assign or actively seek to assign him or her a Take Stock in Children student; 2) That as a part of the Take Stock in Children matching process, additional information may be elicited from the applicant by the Mentor Coordinator; and 3) Take Stock in Children reserves
the right at all times to terminate any match between any volunteer and student, for whatever cause.

Signature*

First Last

Liability Release/Consent for Release of Information*

I have read and agree to the LiabilityRelease/Consent for Release of Information..

I understand if denied acceptance into the mentoring program, no reason for denial will be given. I hereby consent to Take Stock in Children 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 all available records or information from any source, to include but not limited to criminal records.

Take Stock in Children will use this information for the sole purpose of evaluating my ability to meet the initial criteria to serve as a mentor with the Take Stock in Children Program. I hereby release Take Stock in Children from any liability, debt, claim, suit, or obligation of any nature whatsoever in connection with this application.

Signature*

First Last

Phone

This field is for validation purposes and should be left unchanged.

TAKE STOCK IN CHILDREN MENTOR APPLICATION

SECTION ONE - PERSONAL INFORMATION

SECTION TWO - CURRENT EMPLOYMENT

SECTION THREE - SCHOOL PREFERENCE & AVAILABILITY

SECTION FOUR - EDUCATION

SECTION FIVE - SKILLS/INTERESTS

SECTION SIX - BACKGROUND INFORMATION

Personal References

Personal Reference #1

Personal Reference #2

Personal Reference #3

SECTION SEVEN - LEGAL/RELEASES

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