AH4D Volunteer Registration Form

Alumni Mentorship Program Volunteer Mentor Application

Fill out the form carefully for registration.
Angelic Hearts 4 Dooly Inc. is a growing nonprofit organization that is committed to youth excellence. We work with students in grades 9 - 12, parents and caregivers, and stakeholders to ensure lasting impact through teaching advocacy, leadership, guidance, social-emotional intelligence, assertive self-expression, and healthy relationships, giving young adults the skills and confidence to thrive as leaders.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
How were you referred to us?*
Write a brief statement on why you want to participate as a volunteer in the mentoring program?*
Employment History
Company Name #1
Position #1
From Date

MonthDayYear
Date
To Date

MonthDayYear
Date
Company #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Name #2
Position #2
From Date

MonthDayYear
Date
To Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Education Level*
Major/Degree of Study*
Describe any special interests/hobbies or previous projects that may be helpful (include any board experience).*
I would LIKE to work with a child in grade:
Why does having positive self-esteem and confidence matter to you?
List three personal references (other than family members) below.
Name #1*
Contact Info #1*
Name #2*
Contact Info #2*
Name #3*
Contact Info #3*
YesNo

Authorizations
Mentor Release Statement

I, the undersigned, hereby state that if accepted as a volunteer mentor, I agree to abide by the rules and regulations of Angelic Hearts 4 Dooly, Inc. I understand that the Alumni Mentorship program involves spending a minimum of one hour/month at the assigned location. Further, I understand that I will attend a training session, keep in regular contact with my mentee, and communicate with AH4D regularly during this period. I am willing to serve as a volunteer mentor in the 6 month Alumni Mentorship program. If I am unable to complete this obligation I will provide notice to Angelic Hearts 4 Dooly, Inc. staff.

I have not been convicted, within the past 10 years of any felony or misdemeanor classified as an offense against a person or family, or public indecency, or a violation involving a state or federally controlled substance. I am not under current indictment and/or active probation and/or parole sentence.

Further, I hereby fully release, discharge, and hold harmless Angelic Hearts 4 Dooly, Inc. participating organizations, and all the foregoing employees, officers, board of directors, and coordinators from any and all liability, claims, causes of action, costs and expenses that may be or may at any time hereafter become attributable to my participation in the Angelic Hearts 4 Dooly, Inc. Alumni Mentorship program.

I understand that Angelic Hearts 4 Dooly, Inc. staff reserves the right to terminate a mentor from the program. The program takes place within the confines of the program's policies, guidelines and processes and does not encourage or approve inappropriate relationships established between mentor/mentee and family members beyond the organized and supervised activities of the program.

Furthermore, I give permission to Angelic Hearts 4 Dooly, Inc. to request a criminal background check to be conducted by law enforcement as part of the screening for entrance into the program.

This includes verification of personal and employment references as well as any crimes involving moral turpitude (any arrest and/or convictions related to sexual offenses) Angelic Heart 4 Dooly, Inc. 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 the above Release Statement and agree to the contents. I certify that all statements in this application are true and accurate.

Please submit your application and proof of completed criminal background check.
Signature*
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Please complete the background check at the link below.

https://opportunities.averity.com/AH4D

The cost is $20 for Georgia Residence.
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Alumni Mentorship Program Volunteer Mentor Application

Employment History

Authorizations

Mentor Release Statement