Mentor Application
Email address *
Name (First, Middle, Last) *
Your answer
Birth date
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/
DD
/
YYYY
Address, City, Zip, County *
Your answer
Main Phone *
Your answer
Secondary Phone
Your answer
Significant Other (Name, Relationship, Phone, Email, Address)
Your answer
Reference 1 (Name, Relationship, Phone, Email, Address) *
Your answer
Reference 2 (Name, Relationship, Phone, Email, Address) *
Your answer
Reference 3 (Name, Relationship, Phone, Email, Address) *
Your answer
Have you ever been arrested, charged, or convicted of a crime. *
Do you have an insured automobile? *
Have you had any driving citations and/or moving violations in the past 5 years? *
Are you experiencing any physical or mental health problems? *
Are you ever away for extended periods of time? *
Do you have any guns or ammunition in your house? *
Do you smoke? *
Do you have any pets? *
Are you able to insure inappropriate viewing materials are not accessible to youth in your home? *
Do you expect any significant life changes in the upcoming year? *
If needed, please expand on any of the above yes and no questions.
Your answer
How long have you lived in the area? *
Your answer
Why do you want to be a mentor? *
Your answer
Tell us about your educational background (High School, College, trades, professional training) *
Your answer
What is your employment situation? (Where do you work? What's your career field? How long have you had your job? What previous work have you done?) *
Your answer
Have you done any volunteer work or have experience working with kids? Please explain. *
Your answer
What are your interests and hobbies? *
Your answer
Please give a brief description of a child you would like to mentor. (Age range? Personality? Location? Interests/Hobbies?) *
Your answer
Before we continue with the interview and background check, is there anything else you would like to tell us about yourself or any questions you may have?
Your answer
TrueMentors Waiver and Agreement
Release of Information: I understand that my social security and driver's license numbers will be required by the Central Records Division of the Michigan State Police for background checks to be conducted. I understand TrueMentors staff will collect needed information during the in-person interview. I authorize TrueNorth Community services to contact references and to verify my employment. I hereby give my permission for the TrueMentors Program staff to share information which may include personal history, criminal history, driving history, mental diagnosis, and/or any other match relevant information with other agencies, organizations, and/or individual involved with either myself or the TrueMentors Youth I may be matched with. I further understand that checking the box 'I agree' will be considered equal to my signature.

Rejection Policy: It is the policy of TrueMentors to only accept volunteer applicant who will, in the professional opinion of the TrueMentors staff, provide an appropriate adult mentoring opportunity for an eligible child accepted into the TrueMentors Program. In the event that a prospective volunteer is not an appropriate fit for the specific needs of our program, the TrueMentors staff may decide to reject his or her application at any point during the enrollment process. For confidentiality purposes and because the intake process covers such an extensive amount of information, the applicant may or may not be told the reason for rejection. The prospective volunteer agrees to accept the professional decision as final.

Communications: I consent to the publication of my identity including photograph and name in TrueNorth Community Services and TrueMentors Program publications and advertising promotions. I release TrueNorth from any liability for use of images which include myself or family members generated for public relations including but not limited to: printed publications, pictures, videos, television, internet, and electronic media.

Liability Release: I agree to waive and release TrueNorth of any and all liability that could be incurred as a result of my negligence, intentional or unintentional, during my responsibilities as a volunteer for TrueNorth. i further release TrueNorth of all liability with regard to any physical or emotional harm that I may sustain during the time I volunteer at TrueNorth or in any other activity sanctioned by TrueNorth. I agree to indemnify and hold harmless TrueNorth for any costs or liabilities which they may incur as a result of my volunteering at TrueNorth. As a volunteer at TrueNorth, I will receive no financial reimbursement for services rendered.

Confidentiality: Through my volunteer work with TrueNorth programs and services, I will have access to information that is considered private. I acknowledge that this information must not be shared with others. In accepting this volunteer role with the agency, I agree to keep all information about program participants, staff, volunteers, and donors confidential. i will not copy, transcribe, record, or memorize confidential information for any reason other than for the limited purpose of providing the assigned services at TrueNorth.

I have had the opportunity to Read and Understand this agreement and acknowledge that by clicking 'I agree', I am waiving certain legal rights in the event of injury. This agreement shall be governed by and construed in accordance with the laws of the State of Michigan.

By checking 'I agree' below, I accept and agree to the terms contained above. *
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