Please
Return to: TeamMates
Mentoring Program 11850
Nicholas Street, Suite 120 Omaha,
NE 68164 FAX:
402-884-0883 Office
Use Only ________________
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.
How did you hear about TeamMates? Please
be specific –this information is used for new mentor recruitment Radio (channel)
_______________________________ Billboards
____________________________________
Newspaper (name
of newspaper)_________________________ Personal Friend/Acquaintance Television (what channel) ________________________________ Name:
___________________________________ Other _________________________________________________ Identify all service organizations, faith-based entities
or community groups you are affiliated with: Faith Based __________________________
Service Organization___________________ Business/Workplace ____________________
Other: ______________________________ 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____________________________ PhoneNumber________________________
Special medical conditions
the school contact should be aware of:
Please provide the following information on 3
references (required for eligibility).
If you are retired please list an additional friend or
family member reference.
** If you are applying to be a mentor with the Lincoln Public Schools, please include a third reference other than family.
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Friend Reference |
Employer Reference |
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I give permission for TeamMates to run a criminal and
abuse registry check. * Background
checks will be run every three years.
Signed:_____________________________Date:________________________
08/25/2010
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
08/25/2010
AGENCY REQUEST FOR INFORMATION
FROM THE NEBRASKA
ADULT AND CHILD ABUSE
AND NEGLECT REGISTER/REGISTRY
The State of
I
hereby request information from the Nebraska Adult and Child Abuse and Neglect
Registry. I agree to use the requested information to determine whether to hire
or retain the individual to provide care, custody, treatment, transportation or
supervision of children or vulnerable adults.
Agency Name/ Fax: One Source, The
Background Check Company –Fax 1-800-929-8117
Please do not use
abbreviations
Address and Phone Number: P.O. Box
24148, Omaha, NE 68124—Attn Nick Jasa
I hereby
authorize the Division of Children and Family Services to disclose whether I
have an Adult and/or Child Abuse and Neglect Register/Registry record to the
above-named agency.
Print Full Legal Name: (applicant)__________________________________________
___________________________________________ ____________________
Signature (applicant) Date
Current Address:
_____________________________________________________________
(Street/City/State/Zip)
Applicant Date of Birth Applicant
Social Security Number
Other names previously used such as
former married names, maiden name and nick names.
Please Print.
Names and birth dates of your children
and children who have lived with you. Please Print.
Any Address at which you have resided
during the past 20 years. Please Print.