IDM Mentor/Volunteer Application
Name *
Phone number *
Email *
Address *
How long have you lived in this community? (Years, Months) *
Emergency Contact (Name and Phone Number) *
Employment and Educational background
Present Employer/School  *
Type of Work/Job Title/Major  *
High School (Name,  level completed) *
College (Name, dates attended and level completed)
Other Training (Name, dates attended and level completed)
Volunteer Experience
Name of Organization, Location, and Length of Time Affiliated (ex. I Define Me Movement  - St. Louis, MO - 5 years) *
How did you hear about IDM? and why do you want to be a Facilitator/mentor/volunteer *
Are there any special needs we should know of to help you carry out your position *
List any hobbies, skills and interests you are able to share:     *
Please check the areas that interest you most: *
Required
Please indicate the days you are available: *
Required
Have you ever been convicted of a criminal offense? *
Have you ever been convicted of a crime involving bounced checks or stolen money? *
Have you ever been convicted for use or sale of illegal drugs? *
Has your driver’s license ever been suspended or revoked? *
Have you ever been convicted of child neglect or abuse? *
Do you presently hold a valid Missouri Driver’s License? *
Terms of SistaKeeper Empowerment Center
If you agree with the statement below, please provide your initials and date in the space provided.
I hereby authorize the above references to release any information relative to me which may be necessary to determine my qualifications for a Volunteer/facilitator position with iDM. I understand that iDM will conduct a background check on me. I certify that all the information provided in this application is true and complete. I understand that falsification or omissions of any information may be cause for denial of appointment or dismissal if discovered at a later date. I am acquainted with and subscribe to the principles of the I Define Me Movement . I understand that training is required for any position, and I will participate in this training as it is offered. I also understand that membership in IDM is required and that I am expected to abide by the standards and policies of IDM. (If you agree with the above statement, Initial and date below) *
Volunteer Disclosure
Authorization and Release
(If you agree with the above statement, Initial and date below) *
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