Brigid's Hope Mentor Application

Brigid's Hope Mentor Application

So that we can best utilize your experience and interests, please complete this application form as fully as possible.
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
Pronouns

Contact & Employment Information
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Texas Drivers License No.
License Expiration Date

MonthDayYear
Date
Occupation
Employer
Job Title
If your volunteer capacity will include licensed professional pro-bono work, please indicate your specific license and level of license (e.g.: LMSW, LCSW, LPC, LMFT, etc.), license number and expiration date.

Demographic Information
Date of Birth

MonthDayYear
Date
Gender
Race/Ethnicity

American Indian/Alaskan NativeAsianBlack or African AmericanHispanic/LatinoNative Hawaiian/Pacific IslanderWhite
Affiliation (Church, Organization, etc.)

Background Check Information & Consent
Please list any additional names or aliases you have gone by that differ from your legal name:
Please Upload a Copy of Your Photo ID or Passport*

Cancelof
Have you ever been convicted of a felony or misdemeanor?*

YesNo
If yes, please explain:
Have you ever been investigated for any allegations of misconduct?*

YesNo
If yes, please explain:
Consent for Background Check:

I, {name}, hereby authorize Brigid's Hope at The Beacon to conduct a comprehensive background check including, but not limited to, criminal records, motor vehicle records, and verification of personal references. I understand that this background check is a condition of my volunteer service.

I release Brigid's Hope at The Beacon, its employees, and agents from any liability in connection with conducting the background check and using this information for volunteer placement purposes.
Signature*

Clear
Date*

MonthDayYear
Date
Confidentiality Agreement:

As a volunteer at Brigid's Hope at The Beacon, I understand that I may have access to sensitive and confidential information regarding the program participants. I agree to maintain the confidentiality of all such information and to not disclose it to any unauthorized person.
Signature*

Clear
Date*

MonthDayYear
Date