Mentor Application

Thank you for your interest in becoming a mentor with Destination Elevation. Our mentors play a crucial role in supporting individuals and fostering their personal growth. Please complete the following application form to help us understand your background, skills, and motivation to become a mentor.

All information is confidential
Todays Date*

MonthDayYear
Date
Name*

First NameLast Name
Birth Date*

MonthDayYear
Social Security*
123-45-6789
Drivers License*
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

References

Please list at least four persons who can vouch for your reputation, character and morals. Please do not use relatives, spouse or significant other.

-They MUST have known you for at least one year

-One reference MUST be a work or school reference

-One reference should be familiar with your home environment

All information will be treated confidentially and will not be shared
Please include name, address, phone, and email for each reference*
Legal Record

Please list any arrests, convictions, and recent traffic violations
Please include arrest/violation date, charge, and disposition/result*
Please provide a short explanation why you would like to be a mentor*
Statement of Understanding

If I am accepted as a mentor, I understand my obligation to meet with my mentee regularly and to inform Destination Elevation staff as to the status of my mentee/mentor relationship every month. I further agree to accept the supervision of the Destination Elevation staff and discontinue my service if I am requested to do so by the organization. I agree to following the guidelines set forth in the manual I am provided.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date

Authorization For Release of Confidential Information

I understand it will be necessary for Destination Elevation to investigate my background and check my character references. I hereby give my consent for this information exchange. I authorize such agencies and individuals, in addition to the references I have listed, who have relevant information about my ability to develop and sustain a healthy relationship with a child, to release any information requested by Destination Elevation. I release all persons and agencies contacted from any liability due to providing the requested information.

I understand the following types of information may be requested and others deemed necessary: Criminal history; driving record; childabuse/neglect history; employer/work reference

I understand any pertinent information obtained from my application and interview may be shared with the prospective mentee parties. I also give permission for my name and any still or motion picture of me, in relation to my involvement in Destination Elevation to be used for the purpose of public relations, newsletters, or news releases by the organization.
Name*

First NameMiddle NameLast Name
Also Known As*
Date*

MonthDayYear
Date
Signature*

Clear
Social Security #*
123-45-6789
Birth Date*

MonthDayYear
Date
Please list all your addresses for the last 5 years.
Please include the full address and the from/to month and year for when you lived there*
This authorization is voluntary and remains in effect unless specifically revoked by written notice to the organization or person.

Mentor Personal Auto Verification

All mentors must carry auto insurance for the minimum required by the State of North Dakota which enables Destination Elevation to provide excess auto liability protection as needed while in the course of Destination Elevation organization work.
Name*

First NameLast Name
Insurance Agency*
Policy*
Limits
Bodily Injury*
Property Damage*
Combined Limit*
A copy of your driver's license and current insurance card is required. *

Cancelof
**Reminder** Seatbelts must be worn by both the volunteer and the child at all times while driving. It is now the law!

Only the mentor has clearance to provide transportation for the child during their time together. The mentor does not have to drive but should always be within the vehicle. Anyone the mentor uses as transport has a valid license and has insurance on the vehicle being driven. Responsibility cannot be given to anyone else- friend, spouse, etc. Only the parent/guardian of the child may arrange alternate transportation.

By signing below, I agree to notify Destination Elevation of any changes in my auto insurance coverage.
Signature*

Clear
Date*

MonthDayYear
Date

Confidentiality Policy Statement
Access To Confidential Records

In order for Destination Elevation to provide responsible and professional services to mentees it is necessary for mentors, mentees, and parents or guardians of mentees to be asked to divulge extensive personal information about themselves and their families. The organization respects the confidentiality of the mentee and mentor records and, with the exception of situations listed below, shares information about mentee and mentors only among the professional staff and board of directors, as needed. The right to confidentiality applies not only to written records, but also to video, pictures or use of mentee or mentor's name in organization publications.

All records are considered the property of the organization and not the staff, mentees or mentors themselves. In order to provide service, which is in the best interest of the children served by the program, information from outside sources, including confidential references, must be assessed along with information gained from mentors or mentees themselves. Records are not available for review by the mentees or mentors. Mentees and mentors shall sign a statement that he or she has read and understands the organization policy on confidentiality and agrees to program participation under the guidelines it sets forth.

Limits of Confidentiality

1. Information will be released to other individuals or organizations only upon presentation of an authorized "consent to release information" form appropriately signed by the mentee or mentor.

2. Identifying information regarding mentees and mentors may be used in organization publications or promotional materials, if the mentee or mentor has given written permission.

3. Information shall only be provided to law enforcement officials or the courts pursuant to a valid and enforceable subpoena.

4. Information shall be provided to an organization's legal counsel in the event of litigation or potential litigation involving the organization. Such information is considered privileged information and its confidentiality is protected by law.

5. North Dakota state law mandated that suspected child abuse or neglect be reported to the appropriate county social services. All workers/mentors are responsible for staying aware of such reporting requirements of their respective jurisdiction and shall always comply with mandated procedures.

6. If an organization worker receives information indicating that a mentee or mentor may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or report to the local law enforcement authorities.
I have read and understand the above document which stated the organization policy with respect to confidentiality of mentee and mentor records. I agree to program participation under the conditions it set forth.

I will respect the privacy of mentees/mentees' families and mentors of Destination Elevation. Unless I have the appropriate signed release I will not discuss or disclose, directly or indirectly, with any person (except those individuals employed or contracted by Destination Elevation), background and family history or any other information of confidential nature of which I become aware through my involvement with the program.

(For mentors only: I understand I am to use only the first name of the mentee and the mentee family members in introductions, etc. I am not to share with others the last name of the mentee/mentee family.)
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

References

Legal Record

Statement of Understanding

Authorization For Release of Confidential Information

Mentor Personal Auto Verification

Limits

Confidentiality Policy Statement