Mentor Application Form (Page)

Equal Opportunity Policy

Take Stock in Children is an equal opportunity organization and complies with all applicable federal, state, and local non-discrimination laws. Take Stock in Children strictly prohibits and does not tolerate discrimination against students, mentors, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including pregnancy), sexual orientation, gender (including gender nonconformity and gender identity), marital status, age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All Take Stock in Children employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. Take Stock in Children will reasonably accommodate qualified individuals with a disability as required by law. Take Stock in Children will also, where appropriate, provide reasonable accommodations for an individual's religious beliefs or practices. Finally, no one will be subject to, and Take Stock in Children prohibits, any form of discipline, reprisal, intimidation, or retaliation for good faith reports or complaints of incidents of discrimination of any kind, pursuing any discrimination claim, or cooperating in related investigations.

SECTION ONE - PERSONAL INFORMATION

Name*

First Middle Last

Salutation

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Phone Type*

Home
Cell
Work

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*

Race*

Ethnicity: Are you of Hispanic, Latinx, or Spanish origin?*

Yes
No

Age*

Marital Status

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

SECTION TWO - CURRENT EMPLOYMENT

Employment Status*

Employed (Please fill out employer below)
Unemployed (Please fill out previous employer below)
Retired (Please fill out previous employer below)

Employer*

Employer Address*

Street Address Address Line 2 City State ZIP Code

Employer Phone*

Your Title/Position

Employment Start Date*

Department

Previous Employer*

Previous Employer Address*

Street Address Address Line 2 City State ZIP Code

Employer Phone*

Your Title/Position

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?

Are you a first-generation college graduate?*

Are you currently enrolled in any education or training program? If yes, please specify.

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.

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 the following areas? (Check all that apply)

Which of the following activites do you enjoy participating in or watching? (Check all that apply)

Sports
Handicrafts
Outdoor Life
Mechanics/Science
Literature
Pop Culture (Movies, TV, etc.)
Music
Collecting

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

Are there any particular challenges you would prefer not to handle as a mentor?

Yes
No

If yes, please explain:

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

How did you hear about Take Stock in Children?*

Are you a graduate of the Take Stock in Children Program?*

If yes, what year did you graduate and from what county?

SECTION SIX - BACKGROUND INFORMATION

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

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*

If you are currently employed, please print the name and address of your work supervisor. If employed less than 6 months, the previous employer.

First Last

Supervisor's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisor's Phone

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.

Phone

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

SECTION EIGHT - MENTOR POLICY ADHERENCE AGREEMENT

Please initial your approval next to each statement:

As a mentor in the Take Stock in Children program, I will always act in a manner that is in the best interest of my student.
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 College Success Coach if I am unable to attend a previously scheduled meeting.
I will not willfully arrange unmonitored contact with my student or without 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 releationship with my student if I violate any of the above policies.

Signature*

First Last

Comments

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

TAKE STOCK IN CHILDREN MENTOR APPLICATION

Equal Opportunity Policy

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

SECTION EIGHT - MENTOR POLICY ADHERENCE AGREEMENT

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