H.U.T.S. Mentor Application

H.U.T.S. Mentor Application

Complete this professional application and submit it for review.
General Information
Village location applying to serve as mentor
Program applying for as mentor or volunteer
Have you attended a HUTS group session?
How did you learn about The Village Indiana?
Mentor Information
Title
Name

First NameLast Name
Preferred Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
US Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer
Occupation
Work Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
May we contact you at work?
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ethnicity
Languages Comfortable Speaking
Shirt Size
Allergies or Other Information
Application Questions
Motivation to Apply
Other Groups or Organizations Involved With as a Mentor or Volunteer
Belief in God or a Higher Power
Have you ever been convicted of a crime?
If Yes, Please Explain
References
Please provide a minimum of three references who have known you for more than one year and preferably observed you with youth. Do not include more than one family member.
Reference #1 Name
Reference #1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference #1 Email
example@example.com
Reference #1 Relationship
Reference #2 Name
Reference #2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference #2 Email
example@example.com
Reference #2 Relationship
Reference #3 Name
Reference #3 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reference #3 Email
example@example.com
Reference #3 Relationship
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Relationship
Waivers
Photo and Social Media Release
I grant H.U.T.S. permission to use photographs, video, and other media of me taken in connection with the mentor application and mentoring activities for promotional, educational, and social media purposes.
Mentor Agreement
I understand that: 1. My service as a mentor is voluntary and does not create an employment relationship with H.U.T.S. 2. I am expected to behave in a professional, respectful, and responsible manner at all times. 3. I will follow all H.U.T.S. policies, procedures, and safety guidelines while participating in mentor activities. 4. I will maintain appropriate boundaries with students and other participants. 5. I will promptly report any concerns, incidents, or policy violations to H.U.T.S. staff. 6. I may be removed from the mentor program at any time if H.U.T.S. determines that my conduct is inconsistent with program expectations. 7. I understand that participation in the mentor program may involve risks, and I assume responsibility for my own actions. 8. I agree to comply with any additional requirements or training requested by H.U.T.S.
By typing my name below, I acknowledge that I have read, understood, and agree to the Mentor Agreement above, and I intend this typed name to serve as my e-signature.
Should be Empty:

H.U.T.S. Mentor Application

General Information

Mentor Information

Application Questions

References

Emergency Contact

Waivers