Mentor/Volunteer Application Form

Mentor/Volunteer Application Form
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Birthdate*

MonthDayYear
Date
Emergency Contacts*
Have you ever worked, participated, or volunteered at Heart of Oregon Corps?*

YesNo
If yes, what/when?
How did you hear about YouthBuild Mentoring?*
If other, please explain:
If you were referred, who sent sent you?

Employment and Education Information

Please list last three employers chronologically. If you are retired or unemployed, you can write that in occupation and employer name and indicate N/A for other sections.
Configurable list*
Education Level*
Please list any degree(s) or trade certification(s) you hold in addition to any relative trainings and experiences you have: *

Typical Availability Information*

	From	To
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Mentoring Questions
Why do you want to be a Mentor/Volunteer with YouthBuild?*
Do you have any prior volunteering or working experiences with youth?*
What are your interests, hobbies, or special skills?*
What support or resources would you need to be successful at a mentor?*
ie. Graphic Design, Social Media
Do you have any concerns about working with at-rick youth? Please explain: *

References

Please list two personal character references, plus one employer reference. Please list only nonrelatives you have known for at least a year.
References*

Background Screening and Releases
Please read carfully before signing- Photo and Viedo Release:

In consideration of my participation in approved activities of Heart of Oregon Corps or activities related to approved programs of Heart of Oregon Corps, I hereby authorize and grant permission to Heart of Oregon Corps to photograph and/or record me while participating in activities of Heart of Oregon Corps, or activities related to approved programs of Heart of Oregon Corps, and to use, produce, reproduce, copy, publish, distribute, exhibit and/or incorporate, alone or together with other materials, in whole or in part, photographs, videos, or any other means of reproduction of my image, likeness and/or voice obtained as a result of my participation in approved activities Heart of Oregon Corps, or activities related to approved programs of Heart of Oregon Corps. I hereby agree not to bring, or consent to others bringing, any claim, demand or action against Heart of Oregon Corps in any way related to the use, production, reproduction copying, publication, distribution, or exhibition of my image, likeness and/or voice. I further waive and relinquish any and all rights I have or might have to inspect or approve any photograph, videotape image, tape recording or other form of reproduction of my image, likeness or voice.

By signing below, you attest to the truthfulness of all information listed on this application. You agree to let our program confirm all information listed and to conduct a federal and state criminal records check.

I have read and understood the program’s rules, regulations, and responsibilities for becoming a mentor. If selected I will follow the rules of the program and be a dedicated mentor. I agree to the time commitment to my mentee of 4 hours a month for 12 months.
Name*

First NameLast Name
Volunteer Candidate Signature*

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Mentor/Volunteer Application Form

Employment and Education Information

Mentoring Questions

References

Background Screening and Releases