EXPRESS MENTOR APPLICATION

Which Mentorship Program are you signing up for?*

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Civil Status*

SingleMarriedDivorcedWidowed

What is your occupation?*

If you are currently attending college, please notate which college/university it is below.

Mentor Requirements

1. Complete Mentors Application & Interview.
2. Attend Mentors Orientation
3. Pass a criminal background check
4. Agree to:
§ Participate in mentor orientation, and monthly mentor meetings
§ Commitment to developing a relationship of trust and respect with the mentees
§ Support Bethany’s mission, vision, and goals for Mentorship Program
§ Commitment to attend weekly mentoring activities with mentees
§ Stay accessible, committed, and engaged during the length of the program
§ Listen well, provide open and candid feedback
§ Offer encouragement through genuine positive reinforcement
§ Be a positive Christian role model
§ Share “lessons learned” from your own experiences
§ Be a resource and a sounding board
§ Give feedback to the mentees on what is working or not working in the mentoring relationship
§ Contact an Executive Leader as soon as possible about problems connecting with mentees
§ Complete program evaluations

By submitting this form, you are acknowledging that you are committed to actively participate in this mentoring program and will follow the mentor guidelines.

*The Bethany Center for Mentorship reserves the right to refuse participation as a mentor to any individual at our discretion.

Signature for Mentor Requirements*

Mentor Guidelines

In order to participate in the Bethany Mentorship Program, all mentors must follow these guidelines at all times.

PROGRAM RULES
The Bethany Center for Mentorship has rules to ensure compliance with federal, state, and local laws and regulations, and the Bethany Center for Mentorship policy. The rules also are designed to protect and enhance the safety and well-being of all individuals attending the mentorship program. Following these rules at all times is a mandatory requirement.

MEETING WITH YOUTH
1. All meetings and/or activities with youth will take place on the mentorship program campus, or as a part of a Bethany Center for Mentorship sponsored activity/field trip.
2. Off campus contact with mentees are strongly encouraged!! It’s the personal relationship building that helps the mentee develop a strong sense of trust and connection to the mentor. Weekly mentee contact outside of the mentoring program must be reported via the weekly mentor report.

TRANSPORTATION
Transporting youth in your personal car is allowed. However, the youth must have a parental consent to allow their youth to ride in a personal vehicle of a mentor.

PHYSICAL CONTACT
Many of the youth we work with will have a strong need and desire for positive physical contact with caring adults. You are encouraged to be a positive role model however, your physical contacts should be limited to holding a hand, giving a soft pat on the back, or the sharing of a hug in full view of other adults. Make sure that your interactions with youth can never be taken to be inappropriate by those who may observe your activities.

CONFIDENTIALITY
All information you are told about your youth is confidential and sharing that information with others is prohibited. You are not allowed to communicate to your youth that you will keep what they tell you private. You are allowed to tell them that you will keep private any communication that you are not required to report. Adherence to the following rules of confidentiality is very crucial for the safety of both
the mentor and youth:
1. If a youth confides that he or she is the victim of sexual, emotional, or physical abuse you MUST notify the Bethany Center for Mentorship Director immediately.
Make a note of when this information was reported and to whom it was given. Remember this information is extremely personal and capable of damaging lives, so DO NOT share it with anyone except the appropriate authorities.
2. If a youth tells you of their involvement in any illegal activity you must tell the Bethany Center for Mentorship Director immediately. Again, make a note of when this information was reported and to whom it was given. These procedures are for the protection of all youth, mentors, and volunteers participating in the Bethany Center for Mentorship program.

We deeply appreciate your willingness to participate in the Bethany Center for Mentorship program. If you have any questions, or comments, please feel free to call the Bethany Center for Mentorship.

I have read, understand, and agree to strictly abide by the Bethany Center for Mentorship Mentor Guidelines. I understand that failure to comply with these procedures at all times may result in my removal from participation in the program.

Signature for Mentor Guidelines*

Hold-Harmless Waiver

I fully understand, that in participating in the activities at Bethany Church’s
Mentorship Program on behalf of myself, my spouse, my family members and my
child(ren), I am participating in a program that carries certain risks and/or
dangers. I personally assume, on behalf of myself, my spouse, my family members,
and my child(ren) participating and or volunteering in the Bethany Mentorship
Program whether foreseen or unforeseen, and I still wish to proceed.
In participating in the Bethany Church sponsored activities, I hereby voluntarily
release, forever discharge, and agree to indemnify and hold harmless Bethany
Church from all claims, demands, or cause of actions, which are in any way
connected with these activities on behalf of myself, my spouse, my family members,
and my child(ren).
I hereby, agree to waive, release, discharge and hold harmless Bethany Church, it’s
staff, agents, representatives, and volunteers, from any and all liability, acts, causes
of actions, claims, demands, personal injury, death, and other claims whatsoever
arising out of, or in any way connected with myself, spouse, my child(ren) and/or
heirs, executors, administrators, guardians, successor, or assigns by participating in
the Bethany Mentorship program activities.
I warrant that I have read this agreement and fully understand it and that I have
signed it of my own free will and accord without reliance on any representation of
any kind or character not expressed or set forth herein.

Do you agree with the statements listed above?*

Yes

Signature for Hold Harmless Waiver*