The Alternative Roadmap Application
Please fill out each area to the best of your ability
Email address *
First Name: *
Your answer
Last Name: *
Your answer
College/University: *
Your answer
Grade/Education Classification: *
Major: *
Your answer
Phone number: *
Your answer
Birthday: *
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DD
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YYYY
Address: *
Your answer
Facebook Page
Your answer
Instagram Page
Your answer
Why are you applying to work with The Alternative Roadmap? *
Your answer
What do you want to get out of your time with AR? *
Your answer
Do you have access to a vehicle? *
What days are you available to work? *
Required
On the days you are available, what times are best for you? *
Required
Desired Commitment Level *
Why should The Alternative Roadmap bring you on? *
Your answer
Describe yourself in 3 words: *
Your answer
Have you volunteered or interned somewhere before? If so, what were your responsibilities? *
Your answer
What’s your experience with at-risk populations? *
Your answer
Reference #1: (Name, Relationship to applicant, phone number, email address) *
Your answer
Reference #2: (Name, Relationship to applicant, phone number, email address) *
Your answer
Emergency Contact: (Name, Relationship to applicant, phone number, email address) *
Your answer
Have you ever been convicted for a crime, including sex-related or child-abuse related offenses? *
If yes, please explain below: (If "No" please right N/A) *
Your answer
I certify that the answers given in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application as may be necessary for the purposes of determining an appropriate and satisfactory position for me. I understand that this application is not, and is not intended to be, a contract. I understand that false or misleading information provided in my application or interview may result in my not being able to continue as an Navigator with The Alternative Roadmap. *
In signing this agreement, I acknowledge that I have read and understand The Alternative Roadmap's confidentiality policies. I understand and agree that in the performance of my duties as a Navigator of The Alternative Roadmap, I must hold certain information regarding clients, students, Navigators, teachers, employees and volunteers in the strictest confidence. Further, I understand that confidentiality is protected by Federal law (42CF R Part II and Uniform Health Care Information Act) and that any intentional or involuntary violation of the confidentiality with regards to clients, students, Navigators, teachers, employees and/or volunteers may result in disciplinary action including suspension and/or termination. A complete copy of The Alternative Roadmap's Confidentiality Policy can be requested. *
Liability Release: - I hereby release, indemnify and hold harmless The Alternative Roadmap, its officers, directors, board members, interns and employees, and the organizers, sponsors and supervisors of all Alternative Roadmap activities from any and all liability in connection with any injury I may sustain (including any injury caused by negligence) in conjunction with working with The Alternative Roadmap. *
In checking the box below, I agree to be photographed, videotaped and/or recorded by The Alternative Roadmap while participating in the Navigator program with The Alternative Roadmap. I understand that The Alternative Roadmap will own rights to and may use this media (photographs, videotape, recordings and/or my statements), in whole or part, in The Alternative Roadmap materials such as printed publications, The Alternative Roadmap website (www.alternativeroadmap.org), videos, social media, grant proposals and promotional materials to support The Alternative Roadmap and its programs. As far as I know, what I say and do in this media will not violate the rights of any other person or company. If I no longer want my photos and/or story to be used, I agree to contact the Alternative Roadmap Co-Founder at elliot@alternativeroadmap.org. Once requested, The Alternative Roadmap will not create new materials using participants’ media – but we may continue to use already printed materials until we can make replacements. *
Please email your resume and cover letter to:
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