Mentor Application

Today's Date

Date

Mentorship applicants must submit to a drug screen and a have PPD test for tuberculosis prior to working with our consumers. All applicants must be at least 21 years of age to mentor at Vashti. We must also recieve a copy of your driver’s license, social security card and three letters of reference. Mentorship at the Vashti Center is contingent upon a clear Criminal Records Check. If the Criminal Records Check is not clear, mentorship eligibility will be denied. Forms will be provided by the Vashti Center for all required testing. Applicants are considered for mentorship without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of medical condition or handicap. Please understand that false or misleading information on this application is a reason in itself for denial or discharge from mentorship eligibility. All eligible applicants will not begin mentoring consumers of The Vashti Center, Inc. until training has been completed and the Mentoring Program Director has given permission.

Signature

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Present Employer:

Work/Title:

How did you hear about our Mentor Program?

Volunteer Experience:

Emergency Contact

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Relationship to Applicant

What interests you about mentoring at The Vashti Center?

Do you have experience working/volunteering with youth? If so please explain:

Please select your preferences

Pre-Teen GirlPre-Teen BoyTeenage GirlTeenage Boy

What are your days of availability? Please select all that apply

Are you willing to take any necessary training that may be required for our Mentor Program?

PUBLICITY WAIVER AND RELEASE

The Vashti Center may desire to use and publicize my name, likeness, and other personal characteristics for advertising, promotion, and other business purposes. I give The Vashti Center my permission for such use and publicity purposes.

I hereby irrevocably permit, authorize, grant, and license The Vashti Center the rights to display, photograph, digitize, edit, adapt, license, or otherwise use my name, image, likeness, appearance, voice, and other personal characteristics, in magazines, brochures and other print publications, media, motion pictures, television broadcast, display, and other advertising and promotional materials, press releases, the internet, on any platform and for any purpose, including but not limited to advertising, public relations, and promotion of The Vashti Center, without further consent from or royalty, payment, or other compensation to me. The Vashti Center shall be the exclusive owner of all rights, including copyright, to these materials.

CONFIDENTIALITY AGREEMENT

I acknowledge that I may be entrusted with or have access to Confidential Information at The Vashti Center. “CONFIDENTIAL INFORMATION” includes, but is not limited to (1) education records; (2) “protected health information” as defined in the Health Insurance Portability and Accountability Act (“HIPAA”); and (3) other medical information, regarding any residents at The Vashti Center. Confidential Information shall be considered the property of The Vashti Center.

I will not use or disclose Confidential Information except as required as part of my participation in the Activities. I agree not to remove any Confidential Information from the premises of The Vashti Center. Upon the termination of my volunteer activities, or whenever requested by The Vashti Center, I will returned all Confidential information and other documents.

CRIMINAL RECORD CONFIRMATIONS

I hereby confirm, represent, and warrant that I have never been convicted of or charged with a violent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape, or any sexual offense, nor have I ever been ordered by a court to receive psychiatric or psychological treatment in connection therewith. I have also never been a registered sexual offender or sexual predator.

I represent and warrant to The Vashti Center that I am at least twenty-one (21) years of age. I have full right, power, and authority to enter into this Agreement and grant the rights hereunder.

This Agreement constitutes the sole and entire agreement of the parties with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter.

BY SIGNING, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS AGREEMENT AND THAT I ARE GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE VASHTI CENTER.

Signature

Mentor Application

TERMS AND CONDITIONS