Mentor/Volunteer Application

How can you make a difference for a child in need?
Group Mentor
A group mentor in the Mentoring Academy is a positive adult role model who works with a small group of 4-5 students. They support and engage with the group, attending at least one program per week during an 8-10 week semester. If a group mentor forms a strong connection with a student, they are encouraged to establish a one-on-one mentoring relationship with that student.
One-on-One Mentor
After completing an 8-week semester as a group mentor, you may advance to become a one-on-one mentor. In this role, you build a trusting and supportive relationship with a single mentee, meeting for at least 8 hours per month, which can be split among various activities. We encourage a minimum commitment of one year for one-on-one mentoring.
Volunteer
Volunteers assist in organization, administration, program planning, teaching assistance, building beautification and much more. Volunteers join our organization with the intention of community involvement rather than a focus on one-on-one or group mentoring.
Presenter
A presenter works directly with students in our Mentoring Academy with the intention of teaching the assigned group a specific lesson, trade, or life skill.
Please read the descriptions above and check off any role you are interested in:

Group MentorOne-on-One MentorVolunteerPresenter

References
Please provide three references (non-relatives): Current or previous employers, if possible, and at least one reference who has seen you interacting with children:
Reference 1
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Email
example@example.com
What is your relationship?*
Years Known:*
Reference 2
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
What is your relationship?*
Years Known:*
Reference 3
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Email
example@example.com
What is your relationship?*
Years Known:*

Photo Release
I, the undersigned, hereby grant permission to Youth Guidance, United Way, Indian River County and other groups involved with Youth Guidance to photograph me and to record my voice, performances, poses, acts, plays and appearances, and use my picture, photograph, silhouette and other reproductions of my physical likeness and sound and allow the unlimited distribution, advertising, promotion, exhibition and exploitation of these images by any method or device now known or hereafter devised in which the same may be used, and/or incorporated and/or exhibited and/or exploited.

I agree that I will not assert or maintain against Youth Guidance, United Way, Indian River County and other groups involved with Youth Guidance, their successors, assigns and licensees, any claim, action, suit or demand of any kind or nature whatsoever, including but not limited to, those grounded upon invasion of privacy, rights of publicity or other civil rights, or for any other reason in connection with the authorized use of my physical likeness and sound in the Picture as herein provided.

I hereby release Youth Guidance, United Way, Indian River County and other groups involved with Youth Guidance, their successors, assigns and licensees, and each of them, from and against any and all claims, liabilities, demands, actions, causes of action(s), costs and expenses whatsoever, at law or in equity, known or unknown, anticipated or unanticipated, which I ever had, now have, or may, shall or hereafter have by reason, matter, cause or thing arising out of the use of any images as herein provided.
Please review the following statement:*

I have read the foregoing and fully understand the meaning and effect thereof and, intending to be legally bound, I have signed this release.
Signature

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Today's Date:*

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Date

Confidentiality Agreement
I, as a volunteer in the Youth Guidance Mentoring & Activities Program, understand that any information that I learn about the child and his/her family is confidential and cannot be revealed or discussed with anyone without signed permission from the child and parent or otherwise ordered by the courts. Information concerning the child may be discussed with the Executive Director of the Program.

By signing this agreement, I attest that I have read the Volunteer Rules & Regulations and will follow them. I understand that an application to become a mentor/volunteer does not guarantee that I will be matched with a mentee. Youth Guidance is not obligated to accept me as a volunteer and reserves the right to deny any application for any reason. A general denial may be all that is supplied and Youth Guidance is not required to disclose particularities regarding such general denial.
Please review the following statement:*

I have read the above confidentiality agreement and I agree to its terms and conditions.
Volunteer Signature:*

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Today's Date:*

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Date

A1A Fingerprinting

Please print when prompted at the end and bring this form with you.
The following individualFirst Name* Last Name* needs to be fingerprinted for the Youth Guidance Mentoring Academy Program.
The Youth Guidance Mentoring Academy ORI is V31020001.

Thank you for your support.

Please bring this form with you to:

A1A Fingerprinting

865 16th Place

Vero Beach, FL 32960

Contact Number: 772-494-6556

Sincerely,

Youth Guidance Human Resources Department

VECHS Applicant Waiver Agreement and Statement
Please select one of the following:*

I have been convicted of a crime.I have NOT been convicted of a crime.
If convicted, please describe below:
Please select one of the following:*

I do authorize you to release my criminal history records, if any, to other qualified entities.I do NOT authorize you to release my criminal history records, if any, to other qualified entities.
I am a current or prospective (please select one):*

EmployeeVolunteer
Signature:*

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Date:*

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Date
Printed Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Address:*
Should be Empty:

Youth Guidance Volunteer/Mentor Application

Volunteer Profile

Experience

How can you make a difference for a child in need?

Group Mentor

One-on-One Mentor

Volunteer

Presenter

References

Reference 1

Reference 2

Reference 3

Photo Release

Confidentiality Agreement

A1A Fingerprinting

VECHS Applicant Waiver Agreement and Statement