Volunteer Application
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Email
*
Your email
Name:
Your answer
Preferred Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Address:
Your answer
Telephone (c) (w) (h)
Your answer
Contact Preference
Email
Phone
Both
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In case of emergency,contact:
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Marital Status:
Single
Married
Divorced
Widowed
Separated
Level of Education/Degree:
Your answer
Place of Employment:
Your answer
How Long:
Your answer
Position:
Your answer
Supervisor:
Your answer
Languages Spoken
Your answer
Do you have any experience working with youth or young adults?
Yes
No
Clear selection
If yes,please describe: (type of activities/ages of children/professional or volunteer)
Your answer
Have you ever applied with another organization that works with youth or young adults?
Yes
No
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Were you accepted?
Yes
No
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Name of organization:
Your answer
What were your responsibilities:
Your answer
Please list any organizations with which you are currently involved:
Your answer
Have you ever applied to this or a youth program in the past?
Yes
No
Clear selection
If yes, when and where?
Your answer
Present membership in clubs or organizations:
Your answer
Volunteer Service Interest
*
Mentor
Administrative/ Office
Driver
Event Planner
Life Skills Teacher
Other:
Required
Do you have any personal or professional/volunteer experience with the following:
*
Child Abuse
Foster Care
Child Protective Services
Mentoring
Other child service agencies
Required
If yes to any of the above,please elaborate:
Your answer
Are you now receiving or have you received mental health treatment?
Yes
No
Clear selection
If yes, please explain:
Your answer
Have you ever been charged and/or convicted of a misdemeanor?
Yes
No
Clear selection
If yes,please explain:
Your answer
Have you ever been charged and/or convicted of a felony?
Yes
No
Clear selection
If yes,please explain:
Your answer
Have you ever been or are you currently on probation and/or parole?
Yes
No
Clear selection
If yes,please state the offense and the beginning /end dates of probation/parole:
Your answer
Do you now or have you ever had a chemical or alcohol dependency/abuse problem?
Yes
No
Clear selection
Does anyone in your family?
Yes
No
Clear selection
If yes,please explain:
Your answer
Are you currently receiving or have you had treatment for chemical or alcohol dependency/abuse?
Yes
No
Clear selection
Has anyone in your family?
Yes
No
Clear selection
If yes,please explain:
Your answer
Do you have any kind of health impairment that would prevent you from performing Mentor duties?
Yes
No
Clear selection
If yes,please explain:
Your answer
Have you ever been charged or convicted of sexual misconduct(including pornography)?
Yes
No
Clear selection
If yes,please explain:
Your answer
Do you give UP permission to obtain additional information for screening purposes from other sources?
Yes
No
Clear selection
COMMITMENT:
As a mentor,will you be willing to :
Commit 12-18 months to being a mentor
Yes
No
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Participate in UP's initial training program of 9 hours
Yes
No
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Participate in ongoing monthly mentor meetings and workshops
Yes
No
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Visit the youth monthly once matched
Yes
No
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Contact the Mentor Coordinator monthly
Yes
No
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Do you agree that your first six months in the UP program are probationary?
Yes
No
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)
Yes
No
Clear selection
REFERENCES
Please list three personal references(NOT related to you),who we may contact as a character reference?
Name
Your answer
Email
Your answer
Name
Your answer
Email
Your answer
Name
Your answer
Email
Your answer
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.
Your answer
Please provide a short summary about your interest in volunteering with UP.
Your answer
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)
Your answer
***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.
Your answer
3708 EAST 29TH STREET,#219 BRYAN,TX 77802
email:info@upbrazosvalley.org
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