Guest Speaker
Application
Legal Name
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First Name
Last Name
I am interested in volunteering as a:
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Guest Speaker
Please upload a photo of yourself (headshot)
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Phone Number
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Area Code
Phone Number
Date of Birth
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Month
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Day
Year
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Age
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E-mail
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Current Place of Employment
T-Shirt Size
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Please list any certifications you currently hold.
Education
High School Name
Date of Graduation
College
College Major
Date of Graduation
Other Education
Personal Profile
Please, tell us your story.
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I would prefer my youth to be:
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6-8 years
9-10
11-12
13-14
Criminal Background
If your records have been expunged pursuant to applicable law, you are not required to answer yes to the following questions. If you are unsure whether to answer yes, we strongly suggest that you answer yes and fully disclose all incidents to avoid any future risk of embarrassment upon disclosure.
1) Have you ever been convicted of or pleaded guilty to any crimes (including crimes of record which have been expunged and pleas of 'no contest'), including municipal, state and federal?
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Yes
No
2) Have you ever been placed on probation, received a Suspended Execution, Suspended Sentence or Suspended Imposition of Sentence for any offense involving a minor child (a child under 18), or been placed on ANY local, state, or federal sexual registry?
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Yes
No
3) Have you ever been sued in a civil court of law where the allegations in the suit involved illegal, inappropriate, or sexual conduct or contact with a minor child?
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Yes
No
4) Have you ever been subject to any court order involving any sexual, physical or verbal abuse including but not limited to any domestic violence or civil harassment injunction or protective order?
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Yes
No
5) Have you ever resigned, been terminated or been asked to resign from a position, whether paid or as a volunteer, due to a complaint(s) of sexual, physical or verbal abuse of minors? *
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Yes
No
Print Name
Signature
Thank you for your interest in being a part of Take Ch9rge N.E.S.T. Mentoring Program!
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