NRNRC Peer Navigator Program Application

NRNRC Peer Navigator Program Application

The Peer Navigator Program pairs returning citizens and/or justice-involved individuals with others who are navigating similar experiences of reentry. As a mentor, individuals will guide and support mentees by sharing their insights, challenges, and successes, helping them build confidence and a positive path forward. As a mentee, individuals will have the chance to receive mentorship, advice, and encouragement from someone who truly understands the challenges returning citizens are facing. Please complete the form below to apply for a mentor or mentee position with us. This application will not automatically save your application, please save your application using the "Save" function at the bottom of the page to continue your application later. **Please allow at least 20 minutes to complete this application in its entirety** If you cannot access this form, please contact us at (202) 584-1000.
Please review the document below for program eligibility requirements:
Do you understand the eligibility requirements for this program?*

YesNo
What position are you applying for?*

MentorMentee

Referral Form

How did you hear about us?
Referral Information*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Title/ Position*

Employment Information

Please provide information about your employment and/or volunteer history. This section will help us understand your work situation and connect you with relevant resources.
Have you ever been employed?*

YesNo
If "No", please describe:
Employer:*
Most Recent Position Held
Job Title/ Position:*
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Salary:*
(Ex. Hourly or Annual Wages, $17.50/hour or $33,500/ year)
Job Description/ Responsibilities:*
Employer:
Second Most Recent Position Held
Title/ Position:
Second Most Recent Position Held
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Salary:
(Ex. Hourly or Annual Wages, $17.50/hour or $33,500/ year)
Job Description/ Responsibilities:
Work-Related Skills: *
Please be as detailed as possible
Future Employment Goals: *
Certification or Training (Optional)

If you have any certifications, licenses, or vocational training, please list them below:
Certification/ Training:
Issuing Organization:
Issue Date:

MonthDayYear
Date
Expiration Date (If Applicable):

MonthDayYear
Date
Professional References:

Please provide the contact information for at least one individual who can serve as a reference. These references will help us learn more about your background and character. References may include employers, community members, mentors, or others who know you well. Please do not list family members or friends.
Reference:*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Relationship to You:*
Reference:

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to You:

Mental Health Diagnostic Attestation
The National Reentry Network for Returning Citizens will not be held liable for consequences due to any medical diagnosis. If you are experiencing a mental health emergency or need immediate assistance, please contact the crisis hotline at The Access Helpline at 1(888)7WE-HELP or 1-888-793-4357 to get connected to services provided by the Department of Behavioral Health. By proceeding with the intake process, you confirm that you have read, understood, and agree to the terms outlined in this liability disclaimer.*

YesNo
Name*

First NameLast Name
Signature*

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Staff Name

First NameLast Name
Staff Signature

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Date:*

MonthDayYear
Date

Confidentiality Agreement

The National Reentry Network for Returning Citizens
I, First Name* Last Name* , agree with the following statements: I understand that I may encounter confidential information during my time at the National Reentry Network for Returning Citizens (NRNRC). As part of the condition of my participation as a member of NRNRC, I hereby undertake to keep in strict confidence any information regarding any client, employee, or business of NRNRC. All discussions, program material, and member activities are confidential and are not to be shared outside of the organization.
Name

First NameLast Name
Signature*

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Staff Name

First NameLast Name
Staff Signature

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Date*

MonthDayYear
Date

Background Check Authorization

The National Reentry Network for Returning Citizens
Name*

First NameLast Name
Former Name(s) Used:
Social Security Number:*
(Please input without dashes, e.g. 123456789)
Phone Number:*
Please enter a valid phone number.
Identification Number: *
Type of Identification: *
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Move-In Date:*

MonthDayYear
Date
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date

Background Check Authorization

The National Reentry Network for Returning Citizens
I, First Name* Last Name* , hereby authorize The National Reentry Network for Returning Citizens of 1200 U ST NW, Washington, DC 20009 and/or its agents to make investigations of my background, verification of social security number; current and previous residences; references, character, past employment, consumer reports, education, driving records, birth records, and any other public records and civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; including those maintained by both public and private organizations, and all records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for services and/or employment. The information contained in this application is correct to the best of my knowledge.

I hereby consent to The National Reentry Network for Returning Citizens verification of all the information I have provided on my application form. I also agree to execute as a condition of employment/services or a condition of continued employment/services any additional written authorization necessary for The National Reentry Network for Returning Citizens to obtain access to and copies of records pertaining to this information. With regard to the foregoing disclosures, I hereby agree to release any person, company, or other entity from any and all causes of action that otherwise might arise from supplying The National Reentry Network for Returning Citizens with application or any related document, will be sufficient for rejection of my application or for my immediate discharge should such falsifications or misrepresentations be discovered after I am employed.

I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to The National Reentry Network for Returning Citizens or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, including information or data received from other sources.

I hereby release The National Reentry Network for Returning Citizens, and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.
Signature*

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Saff Signature

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Date*

MonthDayYear
Date

Document Submission

Please upload the listed documentation which will assist us in processing your intake application. These may include identification, insurance cards, medical records, or other relevant documents. Your documents will be kept confidential and used solely for your intake process. If you encounter any issues uploading your documents, please contact us at (202) 584- 1000 for assistance.
Government-issued ID:

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Take Photo
Birth Certificate:

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Social Security Card:

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Take Photo
If you cannot provide the documentation listed above, please explain why: *
(If not applicable, input N/A)
Optional Documents:

If applicable, please upload any other documents that may assist with your intake process:
Recent Medical Records:

Cancelof
Prescription History:

Cancelof
Should be Empty:

NRNRC Peer Navigator Program Application

Applicant Information

Contact Information

Emergency Contacts

Referral Form

Participant Intake Assessment

Legal History

Employment Information

Certification or Training (Optional)

Professional References:

Educational History:

Physical Health History

Mental Health Assessment

Medication Information

Mental Health Diagnostic Attestation

Confidentiality Agreement

Background Check Authorization

Background Check Authorization

Client Self-Assessment

Document Submission

Optional Documents: