New Mentor Application

New Mentor Application

Welcome. Thank you for your interest in our mentoring program and for completing this application. All information collected on this application will be kept confidential within the mentoring program.
Applicant Details
First Name*
Middle Name*
Last Name*
Suffix
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
City*

Street Address

Street Address Line 2

State / Province

Postal / Zip Code
State/Province*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postal/Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you live in?*
E-mail*
example@example.com
Phone Number*
What is your date of birth?*

MonthDayYear
Date
What is your gender?*
What is your race/ethnicity?*
How did you hear about us?*
Please Specify
Do you currently have a valid driver's license?*

YesNo
What is your driver's license expiration date?*

MonthDayYear
Date
Please list your driver's license number.
Please list the state your driver's license was issued in.

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you currently have automobile insurance?*

YesNo
What is your auto insurance policy number?
Who is your auto insurance policy through?

Why are you interested in becoming a mentor?*
What is your communication preference?
Do you have previous mentoring experience?*
#1 Please give us three references that you have known for a minimum of a year.
Reference #1 *
First Name
Reference #1 *
Last Name
Reference #1 *
Relationship to you
Reference #1*
Phone Number
Reference #1*
Email Address
Reference #2 *
First Name
Reference #2 *
Last Name
Reference #2 *
Relationship to you
Reference #2*
Phone Number
Reference #2*
Email Address
Reference #3 *
First Name
Reference #3*
Last Name
Reference #3 *
Relationship to you
Reference #3*
Phone Number
Reference #3*
Email Address

Home and Family
What is your sexual orientation?*
What is your marital status?*
If married, please list your spouse's first/last name.
If you have children please list how many.
Do you attend a church?*
If yes, what church?
Where are you currently employed?*
What is your current role?
What is your highest level of education?*
Do you have a criminal history?*
If yes, can you provide a little more information.
Can you provide us with an emergency contact first and last name?*
What is their relationship to you?*
What is their phone number?*

Releases and Agreements
Media Release:

Knoxville Leadership Foundation (KLF) and its programs or various other media may choose to take pictures or videotape participants during events and activities. These images may be used for KLF displays, brochures, newsletters, archives, news releases, publicity and Web sites.I hereby grant permission to Knoxville Leadership Foundation to take and reproduce photographs and videotapes for publication, including publication by news sources and other sources for all educational, trade, advertising and other purposes as determined by Knoxville Leadership Foundation.
Do you agree to the media release?*
Mentor Agreement:

I understand that: The references I listed may be contacted by mail, e-mail or telephone. I am in no way obligated to perform any volunteer services. The information I provided may be used to conduct a background check, to include driving records check, criminal background and sexual offender registry checks and other records where required by local, state, or federal law for volunteers working with youth. I will provide applicable documentation before transporting youth in the vehicle I operate, which includes a valid driver’s license and current automobile insurance. The Knoxville Leadership Foundation is not obligated to match me with a youth and completing this application does not guarantee acceptance into the Amachi Knoxville program. Other youth organizations where I have worked or volunteered may be contacted as references; and as part of the enrollment process, I will be asked to provide additional personal information prior to any recommendations for assignment. Please read this carefully before signing: The Knoxville Leadership Foundation appreciates your interest in becoming a mentor to a youth individually or in a group setting. By selecting 'Yes', you attest to the truthfulness of all information listed on this application. I understand that KLF Mentoring Initiatives include community-based mentoring programs that match at-risk youth with mentors for four to six hours per month for one year. If selected, I will follow the rules of the program and be a dedicated mentor. I agree to the time commitment of meeting one-on-one with a child or in a group setting for four to six hours per month for the duration of one year.
Do you agree to the mentor agreement?*
Confidentiality Policy:

The Knoxville Leadership Foundation respects the confidentiality of mentee and mentor records and, with the exception of situations listed below, shares information about mentees and mentors only among the agency professional staff.All records are considered the property of the agency and not the agency workers, mentees, or mentors themselves. Records are not available for review by the mentees or mentors.

1. Information will be released to other individuals or non-KLF organizations only with the mentee or mentor's written consent.

2. Identifying information regarding mentees and mentors may be used in agency publications or promotional materials unless the clients or volunteer request otherwise.

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

4. Information shall be provided to an agency's legal counsel in the event litigation or potential litigation involving the agency.

5. State law mandates that suspected child abuse be reported to the Tennessee Department of Children's Services.

6. If an agency 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.

7. At the time a mentee or mentor is considered as a match candidate, information is shared between the prospective match parties. The information about the mentor may include such items as: age, sex, race, religion, interests, hobbies, marital and family status, sexual orientation, living situation, etc. Information about the mentee may include such items such as: age, sex, race, religion, interests, hobbies, family situation, etc.
I agree to program participation under the above conditions. I further agree that I will not share identifying confidential information with anyone outside the agency, including family, friends, or community members, without the written consent of the persons involved (parent/caregiver of a mentee, mentee, or the mentor). I also acknowledge that such information should be shared judiciously even within the ranks of the Knoxville Leadership Foundation, only with persons who have a specific need to know the information, and only in situations where others would not overhear such communication.*
Should be Empty:

New Mentor Application

#1 Please give us three references that you have known for a minimum of a year.

Home and Family

Releases and Agreements