TeamMates Mentoring Program

Mentor Application

 

Name                                                                                                        Birth Date                                            

 

Maiden Name or other Legal Names ______________________  School Preference                                                           

 

Address______________________________________ City_________________ State_____  Zip                       

 

Home Phone___________________ Cell Phone_________________________________ 

 

Work Phone___________________E-mail address ________________________________Age______  Gender _____ 

 

The following information is requested for input into our database and is not a determinant of eligibility to be a mentor.

Please select one of the following that best categorizes your current employment (choose ONE only):

  Managerial/Professional (teacher, doctor, social worker etc)                    Technical/Sales/Administrative

  Service                 Military                Law Enforcement/Justice                Religions              Other (specify)____________________

 

NAME OF EMPLOYER_________________________________________   OCCUPATION_______________________________
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Do you speak a foreign Language?    No     Yes  What  language?  ________________________

 

Emergency Contact:  Name____________________________ Phone Number________________________

Special medical conditions the school contact should be aware of:

 

Please provide the following information on 3 references. ** If you are applying to be a mentor with the Lincoln Public Schools, please include a third reference other than family.

 

**Family Reference    

     Friend Reference 

    Employer Reference

Name 

 

 

 

Address

 

 

 

City /State /Zip Code

 

 

 

Home Phone

 

 

 

Work Phone

 

 

 

Relationship

 

 

 

E-mail (opt.)

 

 

 

 

I give permission for TeamMates to run a criminal and child abuse check.  * Background checks will be run every three years.

 

Signed:_____________________________Date:________________________             

07/17/08

 

Text Box:

 

 

 

 

 

 TeamMates Mentor Agreement

 

I, ____________________________________________________(your name) acknowledge that if accepted as a TeamMate Mentor, I agree to abide by the rules and regulations of the TeamMates Mentoring Program.  I understand that the program involves spending time weekly at the assigned school with my student during the school year.  I will be committed to one year in the program and will have the opportunity to renew for another year.  I have not been convicted or had final disposition of a conviction of any felony or misdemeanor classified as an offense against a person or family, or public indecency, or a violation involving a state or federally controlled substance.  I am not currently under indictment.  I give permission for TeamMates to conduct a periodic criminal background check and child/adult abuse inquiry.   Further, I hereby fully discharge school personnel and participating companies or organizations from any and all liability, claims, causes of action, costs and expenses which may be attributable to my participation in the TeamMates Mentoring Program. 

 

In connection with my application to volunteer, I understand that references may be requested that will include information as to my character, work habits, performance and experience.

I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by One Source, The Background Check Company or its agent, to furnish the information described above.  I understand that in the event a decision is made based upon the results of my background check, a report will be furnished to me upon my request.

 

 

I also agree to the following:

 

Ø  To actively participate in training sessions before beginning.

Ø  To be on time for scheduled meetings.

Ø  To sign in on the volunteer registration sheet at the school prior to each visit.

Ø  To notify the school office if I am unable to keep my regularly scheduled meeting with my youth TeamMate.

Ø  To engage in the one-to-one mentoring with an open mind.

Ø  To accept assistance from the student’s teachers and TeamMates Mentoring Program Coordinator.

Ø  To keep discussions with the student confidential, except to inform the teacher or program coordinator about situations that negatively affect the student’s health or welfare.

Ø  To ask the program coordinator when I need assistance or do not understand something.

Ø  To notify the program coordinator of any changes in my employment, address, or phone number.

Ø  To notify the program coordinator of any problems or difficulties with the relationship.

Ø  To notify TeamMates if any criminal charges brought against me while I am a TeamMates Mentor.

Ø  To cooperate with the program’s policies and procedures.

Ø  To allow TeamMates to use my photograph/image or likeness as needed.

 

I understand the TeamMates Mentoring Program reserves the right to deny acceptance to any mentor and to terminate a mentor from the program.

 

I have read the above statements and agree to the contents.  To the best of my knowledge and belief, all statements in my application are true and accurate.

 

_______________________________________________                             __________________________

Signature                                                                                                                       Date

 

07/17/08

 

 

 

 

RELEASE OF INFORMATION

 

I understand that as a condition of my employment, my name will be checked against the Nebraska Department of Health and Human Services Adult/Child Protective Services Central Registers.  A check of these registers is necessary to ensure that I meet provider standards.

 

The purpose of this check will be to determine if my name is being maintained on either register as a result of previous abuse/neglect allegations which have been investigated and have not been determined to be unfounded.

 

To the best of my knowledge, I do not have a conviction or prior history of adult or child abuse/neglect or maltreatment.  Neither have I been convicted of a crime involving moral turpitude.

 

I hereby authorize the Nebraska Department of Health and Human Services to release specific and detailed information contained on the Adult or Child Protective Services Central Register including the information that a record has been found to:

 

­­­­­­­­­­­­­­­­                  One Source, The Background Check  Company            Fax: 1-800-929-8117  Attn: Laura Belyea         

                                                                (Agency/Facility Requesting Check)

 

                P.O. Box 24148, Omaha, NE 68124 Attn: Laura Belyea   Email: lbelyea@onesourcebackground.com     

                                                                (Address – Street, City) 

 

 

 

________________________________                                                                ____________________________

 (Signature of Applicant/Employee)                                                                        (Date Signed)

 

________________________________                                                                ____________________________

(Print or Typed Name of Applicant/Employee)                                                       (Social Security Number)

 

______________________________________________

 

______________________________________________            Other Names Used in Past Twenty (20) Years.

                                                                                                                        (Please Print or Type Legibly.)                               _______________________________________________                         (Use back of sheet if necessary.)                                     

 

_______________________________________________         Other Addresses in Past Twenty (20) Years.

                                                                                                                          (Please Print or Type Legibly.)

______________________________________________                             (Use back of sheet if necessary.)                                                                                                   

_____________________________________________    Complete Addresses REQUIRED (City/State/Zip).

                                                                                              

                                                                                                       

 

________________________________________________           Names of Children Who Have Lived With You.                                                                                       

                                                                                                                          (Please Print or Type Legibly.)

________________________________________________                         (Use back of sheet if necessary.)

 

________________________________________________                                                                                                            

 

 

_____________________                                                               ___________________________________________

(Date of Applicant’s Birth)                                                    (Home Address of Applicant/City/State/Zip)

 

 

__________________________________________________                                           ____________________

(Witness Signature)                                                                                                             (Date Witnessed)

 

               

 

 

 

 

0717/08