Thank you so much for your interest in becoming a Mentor for Hope House of Colorado. We are looking forward to working with you!

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1 Thank you so much for your interest in becoming a Mentor for Hope House of Colorado. We are looking forward to working with you! Our Mentoring Program is designed to help a teem mom become more self-sufficient with the on-going support of a caring adult, a Mentor. Mentors will be working oneon-one with a teen mom as they help guide them through a series of planned meetings. Mentors will be asked to: Attend a training held by Hope House Submit to a background check. Copy of proof of car insurance and driver s license Schedule a meeting with a teen mom that we have matched you with once a week (2-3 hours) Initiate on-going contact with your teen mom (phone, , etc) Attend scheduled Mentoring meetings Be in regular contact with the Mentoring Manager Make a 12 Month commitment It is through this program that we will bring HOPE to a teen-mom and her children. You will be a catalyst for change in their lives. This volunteer position will require an investment of your time and energy, so please prayerfully consider this when you are making a decision about becoming involved. Please call me with any questions that you might have. I would be glad to talk to you. Thank you so much for considering this important role! Enclosed is the application for the program. If you feel that this position would be a good fit for you, please complete the application as soon as possible and send it back along with a copy of your drivers license and proof of your current car insurance. I look forward to hearing from you. Thank you for considering this important program. Jenny Macias/Mentoring Program Coordinator Hope House of Colorado (W) or (C) or (F)

2 Mentor Application Thank you for your interest in becoming a Mentor. The information that you provide will allow us to complete your background check, and help us match you with a teen mom. Hope House reserves the right to decline any applications without giving an explanation. Date: ALL INFORMATION WILL BE KEPT CONFIDENTIAL Legal Name: Nickname: Social Security Number: Street Address: City: State: Zip: How long at this address? If less than five years, please give previous address and number of years below: Years (Street) (City) (State) (Zip) Phone (H) (W) (C) Martial Status (Please circle): SINGLE MARRIED DIVORCED WIDOWED Husband s Name(if applicable): Emergency Contact Name: Relationship: Phone Number: Ethnic Origin (Please circle): AFRICANAMERICAN ASIAN HISPANIC CAUCASIAN OTHER:

3 Birth Date: Age: Languages (other than English): Occupation: Employer: REFERENCES: Name: Address: Phone: Relationship: Name: Address: Phone: Relationship: Name: Address: Phone: Relationship: Please circle words that describe your personality: SPIRITUAL SENSITIVE QUIET OUTGOING ADVENTURSOME HAPPY SHY TALKATIVE CONFIDENT MOODY NERVOUS FRIENDLY ENTHUSIASTIC IMPATIENT IMPULSIVE SERIOUS GOOD-NATURED ASSERTIVE BOLD CHEERFUL OTHER: Please list any special interests, skills, hobbies or areas of expertise:

4 Please list examples of any prior volunteer experience with teenagers: How did you find out about Hope House of Colorado? Why would you like to volunteer to work with teen mothers and their children? Do you have a personal relationship with Jesus Christ? Describe: If you are a regular attendee at church, which church do you attend?

5 The following questions are part of the process to help provide a safe and secure environment for our teen mother s. All information is held in strict confidentiality by the Mentoring Program Manager, Program Director and Executive Director. It is our desire to work with you and have you be a part of this rewarding program. Describe your use of alcohol and or drugs: What is your current state of health? Do you have any physical impairment? Have you ever been a victim of physical, sexual, or emotional abuse? Have you ever been involved in a case of child abuse of child neglect? Have you ever been accused or convicted of the use or sale of illegal drugs? Have you ever been hospitalized, treated for, or struggled with alcohol or substance abuse? Have you ever been convicted of a misdemeanor or a felony?

6 We conduct background checks on all applicants. Do you have any objections? If you answered yes to any of the above questions, please explain: Is there anything else we need to know about you? I hereby affirm that all the information provided is true to the best of my knowledge. I understand that any false information or misleading information on the application will be grounds for this application process to be terminated. I understand that any information obtained by Hope House during the application process will remain confidential. I certify that I have made no willful misrepresentations or omissions in this application, and that the entries made by me above are true, complete and correct tot the best of my knowledge. Any willful misrepresentation or falsification of this application will cause my disqualification for participation in the projects and /or immediate termination if discovered later. Date: Signature: I have included a current copy of my driver s license. I have included a current copy of my automobile insurance.

7 DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT, VOLUNTEER, OR PROGRAM PARTICIPATION PURPOSES Please Read Carefully Before Signing the Authorization DISCLOSURE In considering you for employment, volunteering, or program participation and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, Hope House of Colorado ( the Company ) may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc. For explanation purposes: a consumer report is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and an investigative consumer report is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act ( FCRA ). Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment, volunteer, or program participation purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

8 AUTHORIZATION I have read and understand the foregoing Disclosure, and authorize the Company to obtain and rely upon consumer reports or investigative consumer reports in considering me for employment, volunteering, or program participation and, if I am employed, in considering me for subsequent promotion, assignment, reassignment, retention, or discipline. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in the employment, volunteering, or program participation decision about me. For employment purposes: I do do not authorize you to contact my current employer for Employment and Reference Verifications (This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.) I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company. Applicant Signature Date

9 Personal Data Last Name First Name Middle Name Current Address Dates Lived Here Addresses for the Past Seven Years: (include street, city, state, zip code) Dates of Residence: Date of Birth Other Names Used (including maiden name) Years Used Social Security Number Driver's License # State address (may be used for official correspondence) I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request. I certify that all of the 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 and in any interviews will be sufficient grounds for rejection of employment, volunteering or program participation. Printed Name Applicant Signature Date

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