Mentor Application Please Type or Print Date of Application First Name Middle Name Last Name HOME INFORMATION: Home Address City State Zip Code ( ) ( ) Home telephone # Home fax # Best time to contact you at home ( ) Mobile phone # Home email address How long have you lived at this address? How long did you live at your previous address? WORK/BUSINESS INFORMATION: Primary Industry (e.g., education, medicine, the arts): Primary Professional Role (e.g., teacher, nurse, musician): Employer s Name Title Address Suite # City/State/Zip Code Business hours How long with current employer? Can you be contacted at work? Yes No If yes, what is the best time to call? ( ) Work phone # Ext. Office email address ( ) Work fax # How long were you employed at your previous workplace? Page 1 of 10
DEMOGRAPHIC/MISCELLANEOUS INFORMATION: Male Female Social Security Number Birth date Age Birthplace Marital Status: (Circle One) Single Married Partnered Divorced/Separated Other Spouse/Partner s Name (If applicable): Do you have any children? Yes No If yes, please list names and ages Ethnicity (optional): Check all that apply: Asian Caucasian Pacific Islander African Latino/Hispanic Other: African-American Middle Eastern Caribbean West Indian/Native American Further specification, if relevant (e.g., Salvadorian, Ethiopian, Filipino): Auto Insurance Company: (if applicable) Policy # Driver s License #: Expiration date: State OR ID Card #: Expiration date: State Do you smoke cigarettes? Yes No Have you ever been convicted of a crime? Yes No If yes, please describe: EDUCATION: (Please check all that apply) H.S. Diploma/GED Certification Name/Location: Certification Credential Specify: Specify: Partial Undergraduate AA (Associates Degree) Bachelors/Undergrad degree Partial Graduate School Name of Community College: Name of College: Name of Grad School: Page 2 of 10
Masters Graduate School D.D.S. (Dental Degree) J.D. (Law Degree) M.D. (Medical Degree) Ph.D. Name of Grad School: Name of Dental School: Name of Law School: Name of Medical School: Area of Degree/Name of School: BACKGROUND/AVAILABILITY: Please describe your experience, if any, working with children and/or teenagers (Note: Lack of experience does not disqualify you from mentoring): Are you fluent in any foreign language? Yes No If yes, which one(s)? Within what radius from your home are you comfortable traveling to meet your student (e.g. 10 miles, 15 miles, etc)? Can you commit to participate in the AFC Youth mentoring program for a minimum of one year from the time you are matched with a student? Yes No Do you feel you can meet the AFC minimum requirement of spending at least four hours per month with a student and have contact at least once per week? (Please explain any particular scheduling issues) Yes No Are you currently under a physician s care or taking any medications? Yes No If yes, please provide a list of all medications that you are taking with your application. Do you have any physical restrictions that we should be aware of? Yes No Do you drive? Yes No If no, do you have reliable transportation for your mentee and yourself during outings/events? Yes No If so, please describe means of transportation: Please list below any changes you are anticipating in the next year or so in the following areas, and give an estimated date for each of them. (Write none when no changes are expected): Anticipated changes in personal life (marriage, baby, etc.): Anticipated changes in residence: Page 3 of 10
PROGRAM IDENTIFICATION QUESTIONS: 1. How would you describe yourself as a person? 2. How would your friends, family, and co-workers describe you? 3. Have you ever been arrested or convicted of a crime? Yes No If yes, what were the circumstances? 4. Have you ever used illegal drugs? Yes No If yes, what substances were used and how often? 5. Are you currently using any illegal drugs or controlled substances? Yes No 6. Do you drink alcoholic beverages? Yes No If yes, what and how often? 7. Have you ever been convicted of a DUI, driving while under the influence of alcohol? Yes No If yes, when and what were the circumstances? 8. Do you use tobacco products? Yes No If so, what and how often? 9. Have you ever received treatment for alcohol or substance abuse? Yes No If yes, please explain: 10. Have you ever been treated or hospitalized for a mental disorder? Yes No If yes, please explain: 11. Have you ever been investigated or convicted of child abuse or neglect? Yes No If yes, please explain: 12. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? Yes No If yes, please explain: 13. Are you willing to communicate regularly and openly with program staff, provide monthly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program? Yes No 14. Are you willing to attend an initial mentor training session and two in-service training sessions per year after being matched? Yes No Page 4 of 10
Please read this carefully before signing: Ambassadors For Christ Youth Ministries appreciates your interest in becoming a mentor. Please initial each of the following: I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship. I understand that Ambassadors For Christ Youth Ministries is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor. (optional) I agree to allow Ambassadors For Christ Youth Ministries to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials. I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed: Copy of your valid driver s license and proof of auto insurance Information Release Form Personal References Form Interest Survey Form DMV Release Form (state agency form) Criminal History Release Form (state agency form) Child Abuse and Neglect Release Form (state agency form) Sexual Offender Release Form (state agency form) By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions. Signature Date Please return this application and the items listed above via contact information below: Fax: Attn: Casondra Brown 281-972-9328 or Email: CBrown@afcyouth.org Page 5 of 10
Personal References Please list the names, addresses, and phone numbers of three people you would like to use as character references (only people you have known for at least a year). Include at least one relative. Any information that Ambassadors For Christ Youth Ministries gathers from these references will be held as confidential and not released to you, the applicant. Relative s Name: Address: City: State: Zip: Phone: Relationship: How long known: Name: Address: City: State: Zip: Phone: Relationship: How long known: Name: Address: City: State: Zip: Phone: Relationship: How long known: Page 6 of 10
Mentor Interest Survey Name: Date: Please complete all the following. This survey will help Ambassadors For Christ Youth Ministries know more about you and your interests and help us find a good match for you. What are the most convenient times for you to meet with your mentee? Please check all that apply. Weekdays: Lunchtime: After school: Evenings: Weekends: Other: Please indicate age group(s) you are interested in working with: Age: 11 14 15 18 Ethnicity: Do you speak any languages other than English? If so, which languages? Would you be willing to work with a child who has disabilities? If so, please specify disabilities you would be willing to work with. What are some favorite things you like to do with other people? What are your favorite subjects to read about? What is your job and how did you choose this field? What is one goal you have set for the future? If you could learn something new, what would it be? What person do you most admire and why? Describe your ideal Saturday. Please check all activities you are interested in: Biking Camping Science Cooking Library Hiking Boating Music Sports Yoga Golf Swimming Gardening Parks Movies Fishing Animals/ Pets List any other areas of strong interest: Painting/ Photos Page 7 of 10 Board Games Shopping
CONSUMER REPORT DISCLOSURE AND AUTHORIZATION As part of our hiring process, AMBASSADORS FOR CHRIST YOUTH may request Consumer Reports and/or Investigative Consumer Reports from an Investigative Reporting Consumer Reporting Agency solely for employment related purposes. The nature and scope of this investigation may include but is not limited to your employment history, education, credit, criminal history, character, general reputation, personal characteristics, and mode of living and may involve a review of criminal records and records of the local Department of Motor Vehicles. AMBASSADORS FOR CHRIST YOUTH may obtain one or more consumer reports on you, from one or more consumer reporting agencies, for the purpose of evaluating you for employment request, and, if the undersigned is already employed by this company, for purposes of promotion, reassignment, or retention as an employee. The name of the Investigative Consumer Reporting Agency conducting this investigative consumer report is: Integra Employment Screening, 918 Mill Valley Sugar Land, TX. 77498 PH: 713-870-5923 You are being given a copy of the "Summary of Your Rights Under the Fair Credit Reporting Act" prepared pursuant to 15 U.S.C. section 181 (g & c). You have the right to request additional disclosures of the nature and scope of the investigation and a statement of your rights. For California Residents: Summary of Section 1786.22 (California Civil Code): You are entitled to find out from an ICRA what is in the ICRA s file on you with proper identification. An investigative consumer reporting agency shall supply files and information during normal business hours and on reasonable notice. Files maintained on a consumer shall be made for the consumer's inspection as follows: In person, by certified mail, by telephone (with proper identification for disclosure). The consumer reporting agency shall provide trained personnel to explain to the consumer and information furnished him and written explanation of any coded information. The consumer shall be permitted to be accompanied by one other person of his or her choosing. By signing below you also acknowledge receipt of this notice regarding background investigations pursuant to California Law. Please check this line if you would like to receive a copy of a consumer report if one is obtained by AMBASSADORS FOR CHRIST YOUTH. New York applicants or employees only: You have the right to inspect and receive a free copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified above directly. Minnesota and Oklahoma applicants or employees only: Please check this line if you would like to receive a copy of a consumer report if one is obtained AMBASSADORS FOR CHRIST YOUTH AUTHORIZATION: I have read and understand the foregoing and hereby authorize this company to obtain one or more consumer reports on me for the purposes described above, including, if requested, obtaining a credit report from a consumer credit reporting agency. I understand that this disclosure and authorization covers (1) consumer reports obtained in connection with my application for employment request and (2) if I am hired additional consumer reports may be obtained during my tenure. Please Print Your Name Today's Date Your Signature Page 8 of 10
BACKGROUND CHECK RELEASE FORM I, (print your name LEGIBLY) am aware that AMBASSADORS FOR CHRIST YOUTH has requested Integra Employment Screening to perform a background check in connection with my employment application. Any information obtained as a result of such an investigation is confidential and will be provided only to AMBASSADORS FOR CHRIST YOUTH. I have voluntarily provided the information listed below and in my employment application and understand that false, misleading, or omitted information may be grounds for termination now or in the future. I am fully aware of the purpose for this background check, and therefore request that people, companies, references, current or former employers, schools, government agencies, any and all credit reporting agencies and others contacted provide applicable information to Integra Employment Screening. I release all of those mentioned above, from any liability whatsoever for this purpose. Integra Employment Screening is a professional pre-employment background investigation firm performing background checks as its normal course of business. Integra Employment Screening may make an investigative report in which information is obtained through business associates, financial sources, credit reporting agencies, educational institutions, law enforcement agencies, or other third parties with whom I may be acquainted. If requested by AMBASSADORS FOR CHRIST YOUTH, I hereby authorize Integra Employment Screening to obtain a copy of my credit report from any or all credit reporting agencies it deems necessary in order to perform this background check and to make available this report to AMBASSADORS FOR CHRIST YOUTH. Further, a comprehensive criminal search may be performed, and I voluntarily release from any liability whatsoever, all parties, persons, companies, institutions, government agencies, courts, police departments, or others for furnishing such information. I have the right to request additional disclosures regarding the nature and scope of this investigation. I hereby release my date and year of birth for the purpose of the criminal investigation. I have read and understand that I am releasing all of those listed above from any liability whatsoever for the purpose of obtaining or furnishing background information on my personal history. I further acknowledge and agree to indemnify and hold Integra Employment Screening and AMBASSADORS FOR CHRIST YOUTH harmless from and against any and all claims, demands, or liabilities, including court costs and attorneys' fees, arising from or in connection with any pre-employment background check, including the ordering of credit reports, the researching of criminal history, employment history, education, and driving records. I understand that by signing this document I am agreeing and giving permission to perform this background check. I authorize that a copy of this authorization may be considered as valid as an original. PLEASE PRINT LEGIBLY: If you are currently employed, may we contact your current employer? YES NO Please print your name Current Home Address City, State, and Zip Code Maiden Name (if applicable) Other Names you have been known by: Social Security Number Name as shown on Social Security Card Page 9 of 10
Your Driver's License Number State Issued Name as shown on Driver's License Your date and year of birth is required for the Criminal Search. You may provide your date and year of birth on this form, or if you would like, Integra Employment Screening will contact you for this information. My date and year of birth are / /. I may be reached at the following day time phone number ( ). Other Counties you have lived in during the past 10 years: County State County State County State Signature Today s Date Page 10 of 10