Heartlink Mentor Application

Heartlink Mentor Application

Thank you for your interest in Heartland for Children’s Heartlink Mentoring Program! We appreciate caring adults, such as yourself, willing to volunteer and commit to supporting, guiding, and being a friend to a young person in your community. Please fill out the application to the best of your ability.
Mentor Role Description

The Heartlink Mentoring Program of Heartland for Children helps to empower youth in the foster care system to make positive life choices that enable them to maximize their potential. The mentoring program uses adult volunteers to commit to supporting, guiding, and being a friend to a young person for a period of at least twelve (12) months. By becoming part of the social network of adults and community members who care about the youth, the mentor can help youth develop and reach positive academic, career, and personal goals.

Mentor Role
- Take the lead in supporting a young person through an ongoing, one-to-one relationship
- Serve as a positive role model and friend
- Build the relationship by planning and participating in activities together
- Strive for mutual respect
- Build self-esteem and motivation
- Help set goals and work toward accomplishing them
Time Commitment
- Make a 12-month commitment
- Spend a minimum of 4 hours per month one-on-one with a mentee
- Communicate with mentee weekly
- Attend an initial 2-hour training session and additional 2-hour training sessions twice during each year of participation in the program
- Attend mentor/mentee group events, mentor support groups and program recognition events
Participation Requirements
- Be at least 21 years old
- Reside in Polk, Highlands or Hardee counties
- Be interested in working with young people
- Be willing to adhere to all program guidelines
- Be willing to complete the application and screening process
- Be dependable and consistent in meeting the time commitments
- Attend mentor training sessions as prescribed
- Be willing to communicate regularly with program staff, submit activity information and take constructive feedback regarding mentoring activites
- Have access to an automobile, auto insurance and a good driving record
- Have a clean criminal history
- No use of illicit drugs
- No use of alcohol or controlled substances in an inappropriate manner
- Not currently in treatment for substance abuse and have a non-addictive period of at least five years
- Not currently in treatment for a mental health disorder or hospitalized for such in the past three years
Desirable Qualities
- Willing listener
- Encouraging and supportive
- Patient and flexible
- Tolerant and respectful of individual differences
Benefits
- Personal fulfillment through contribution to the community and individuals
- Satisfaction in helping someone mature, progress and achieve goals
- Training sessions and group activities
- Participation in a mentor support group
- Mileage and expenses are tax deductible
- Personal ongoing support and supervision to help the match succeed
- Mentee/mentor group activities, complimentary tickets to community events, participant recognition events
Application and Screening Process
- Written application
- Driving record check
- Criminal history check: local, state and federal criminal history and sexual offender registry
- Personal interview
- Provide two personal references
- Attend mentor training
If you understand and want to continue with the application and screening process please sign and date below.
Signature*

Clear
Date*

MonthDayYear
Date

How did you hear about the Heartlink Mentoring Program?*
Write a brief statement on why you with to be a mentor.*
Do you have any previous experience volunteering or working with youth? If so, please share.*
What qualities, skills or other attributes do you feel you have that would benefit a youth? Please explain.*
Please provide two personal references (other than family members)*
List the last three places of employment with the most recent first:*
State the addresses where you have lived for the last five years (begin with the recent after the current one):

Please read this carefully before signing:

Heartlink Mentoring Program appreciates your interest in becoming a mentor.

Please initial each of the following:
Initial I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship.

Initial   I understand that Heartlink Mentoring Program is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.

Initial   (Optional) I agree to allow Heartlink Mentoring Program to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed:
- Copy of your valid driver's license and proof of auto insurance
- Information Release Form
- Personal References Form
- Insterest Survey Form
- DMV Release Form (state agency form)
- Criminal History Release Form (state agency form)
- Sexual Offender Release Form (state agency form)
By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
Signature

Clear
Date

MonthDayYear
Date

Information Release
I,full name , understand it will be necessary for Heartlink Mentoring Program to conduct a background check regarding my driving record, criminal history, personal references, and employment.

I authorize Heartlink to obtain any needed information regarding my driving record, legal/criminal history, character references, and employment from any state or federal agency, my employer, and personal references for the purposes of participating in a mentoring program. Further, I provide permission for Heartlink to conduct the same investigation of my background in previous states in which I have resided.

Further, I understand that information about myself will be anonymously (without my name) shared with a prospective mentee(s) and his/her parent(s)/guardian(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and any other information known about me may be shared with the mentee and parent/guardian to ensure and aid in facilitating a safe and successful match relationship.
Signature

Clear
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Social Security Number
Current Driver's License #:
State Driver's License Issued
Please list any other cities, states, and dates of residency during the past 10 years.*

Mentor Interest Survey
Name: blanks Date:blank
Please complete all the following. This survey will help Heartlink Mentoring Program know more about you and your interests and help us find a good match for you.
What are the most convenient times for you to meet your mentee? Please check all that apply.

WeekdaysLunchtimeAfter schoolEveningsWeekendsOther
Please indicate age group(s) you are interested in working with:

Ages 11-14Ages 15-18Ages 19-23
Ethnicity:
Do you speak any languages other than English? If so, which languages?
Would you be willing to work with a child who has disabilities? If so, please specify disabilities you would be willing to work with.
What are some favorite things you like to do with other people?
What are your favorite subjects to learn about?
What is your job and how did you choose this field?