Volunteer Application
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Email *
Name:
Preferred Name:
Date of Birth:
MM
/
DD
/
YYYY
Address:
Telephone (c) (w) (h)
Contact Preference
Clear selection
In case of emergency,contact:
Marital Status:
Level of Education/Degree:
Place of Employment:
How Long:
Position:
Supervisor:
Languages Spoken
Do you have any experience working with youth or young adults?
Clear selection
If yes,please describe: (type of activities/ages of children/professional or volunteer)
Have you ever applied with another organization that works with youth or young adults?
Clear selection
Were you accepted?
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Name of organization:
What were your responsibilities:
Please list any organizations with which you are currently involved:
Have you ever applied to this or a youth program in the past?
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If yes, when and where?
Present membership in clubs or organizations:
Volunteer Service Interest *
Required
Do you have any personal or professional/volunteer experience with the following: *
Required
If yes to any of the above,please elaborate:
Are you now receiving or have you received mental health treatment?
Clear selection
If yes, please explain:
Have you ever been charged and/or convicted of a misdemeanor?
Clear selection
If yes,please explain:
Have you ever been charged and/or convicted of a felony?
Clear selection
If yes,please explain:
Have you ever been or are you currently on probation and/or parole?
Clear selection
If yes,please state the offense and the beginning /end dates of probation/parole:
Do you now or have you ever had a chemical or alcohol dependency/abuse problem?
Clear selection
Does anyone in your family?
Clear selection
If yes,please explain:
Are you currently receiving or have you had treatment for chemical or alcohol dependency/abuse?
Clear selection
Has anyone in your family?
Clear selection
If yes,please explain:
Do you have any kind of health impairment that would prevent you from performing Mentor duties?
Clear selection
If yes,please explain:
Have you ever been charged or convicted of sexual misconduct(including pornography)?
Clear selection
If yes,please explain:
Do you give UP permission to obtain additional information for screening purposes from other sources?
Clear selection
COMMITMENT:
As a mentor,will you be willing to :
Commit 12-18 months to being a mentor
Clear selection
Participate in UP's initial training program of 9 hours
Clear selection
Participate in ongoing monthly mentor meetings and workshops
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Visit the youth monthly once matched
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Contact the Mentor Coordinator monthly
Clear selection
Do you agree that your first six months in the UP program are probationary?
Clear selection
Do you agree to maintain liability insurance for your vehicle throughout your program participation?(please attach with this application a proof of insurance)
Clear selection
REFERENCES
Please list three personal references(NOT related to you),who we may contact as a character reference?
Name
Email
Name
Email
Name
Email
Essay Questions
Please answer the following questions below.There are no right answers to these questions,but provide us with insight into your background and desire for volunteering.
Please write a brief autobiography.Be sure to include any historical information you feel especially shaped your life.Include information about your childhood,current family,and current lifestyle,such as career,hobbies interests,etc.
Please provide a short summary about your interest in volunteering with UP.
ACKNOWLEDGEMENT AND DECLARATION:
"I am interested in becoming a volunteer and know no reason why I shouldn't be assigned to a youth in the program.I am aware that the youth in the program have been abused,neglected or abandoned by adults,and since I do not want to be another cause of disappointment to the youth,I agree to a minimum commitment of one year to the youth and case to which I am assigned."
THE UNDERSIGNED ACKNOWLEDGES AND AGREES THAT:
1.UP Mentoring retains the right to refuse any individual that it feels would not be in the best interest of the program and,further that UP is not required to state the reasons for non-acceptance,and that 2.The volunteer's file is held in strictest confidence and becomes the property of UP Mentoring.I have truthfully responded to all the questions on this application (please provide date and signature)
***Please attach the enclosed Release of Information for remittance with this application.Our program does not accept applicants if they,or an immediate family member,have been convicted,or have prior charges,or have charges pending for a felony or misdemeanor involving and sex offense,violent act,child abuse or neglect,delivery of illegal drugs or related act that would pose risk to children or to the program's credibility.
3708 EAST 29TH STREET,#219 BRYAN,TX 77802
email:info@upbrazosvalley.org
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