As a volunteer mentor in the National Native American Mentoring Program, I First Name Last Name
List the addresses you have lived for the last five (5) years, beginning with the most recent after the current address listed above.
Please provide three (3) personal references (other than family members).
I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of the Mentoring Program and the Boys & Girls Club (hereafter known as the "Club"). I understand that the program involves spending a minimum of one hour per week at the Club. I am not allowed to take the youth off the Club grounds. Further, I understand that I will attend a training session, keep in regular contact with my mentee, and communicate with staff regularly during this period. I am willing to commit to one year in the program and then may e asked to renew for another year.
I have not been convicted of (a) any felony of any kind, or any misdemeanor involving (b) harm or threat of harm to another person, (c) controlled substances, (d) acts of a sexual nature, or (e) cruelty to animals. I am not under current indictment. Further, I hereby fully release, discharge, and hold harmless the Club, participating organizations, and all of their employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs, and expenses which may be or may at any time hereafter become attributable to my participation in the Mentoring Program.
I understand that the Club staff reserves the right to terminate a mentor from the program. The program takes place only at the Club and does not encourage or approve of relationships established between mentor/mentee and family members beyond the organized and supervised activities of the program. I give permission for program staff to conduct a criminal background check as part of the screening for entrance into the program. This includes verification of personal and employment references as well as a criminal check with the authorities. Program staff has final right of acceptance of applicant into the program and reserves the right to terminate a mentor from the program at any time. I have read this Release Statement and agree to the contents. I certify that all statements in this application are true and accurate.
As a volunteer mentor in the National Native American Mentoring Program, I First Name Last Name, agree to: