Please provide the following information for three (3) personal references including your supervisor at work and a friend who has known you at least two years. Please do not use relatives.
***All of the above information is true to the best of my knowledge. I understand that I am not obligated, if called upon, to perform volunteer mentor services herein applied for, and that The Mentoring Network, Inc. is not obligated to assign, or actively seek to assign, a student to me. I further agree to allow the staff of The Mentoring Network, Inc. to elicit additional pertinent, personal information as part of the screening process.
In the event that I am chosen to mentor a youth, I agree to the commitment and to participate to the best of my ability. I will honor confidential information regarding my student. I will be free of the influence of alcohol or illegal drugs when with students. I will inform the Director/CEO of any changes in my address and/or phone numbers. I will inform the Director/CEO in advance should I choose to terminate participation in the program. ***
Please initial the following statements if you are in agreement:
Access to Confidential Records
In order for The Mentoring Network, Inc. to provide responsible and professional services to students, it is necessary for volunteers, students, and parents/guardians of students to be asked to divulge personal information about themselves and their families. The program respects the confidentiality of student and volunteer records and, with the exception of situations listed below, shares information about the students and volunteers only among the appropriate program staff. The right to confidentiality applies not only to written records and conversations, but also to video, film, pictures, or use of student or volunteer names in agency publications.
All records are considered the property of the program and not program workers, students, parents/guardians, or volunteers themselves. In order to provide a service that 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 the students, parents/guardians, or volunteers themselves. Records are not available for review by the students, parents/guardians, or volunteers. Parents/guardians and volunteers shall be provided at the time of application with a copy of this statement on confidentiality along with the exceptions, which define the limits of the confidentiality. Parents/guardians and volunteers shall sign a statement that he/she has read and understands the program’s policy on confidentiality and agrees to follow the guidelines it sets forth.
Limits of Confidentiality
1. Information will be obtained from and/or released to other individuals or organizations only upon presentation of an “Authorization to Release Information” form appropriately signed by the parent/guardian or volunteer.
2. Identifying information regarding students and volunteers may be used in agency publications or promotional material only in the event that the parent/guardian or volunteer has given permission.
3. A violation of the Project’s confidentiality policy by a staff member will be subject to disciplinary actions up to and including dismissal.
4. Information shall only be provided to law enforcement officials or the courts pursuant to a valid and enforceable subpoena.
5. Information shall only be provided to the program’s legal counsel in the event of litigation or potential litigation involving the program. Such information is considered privileged, and it’s confidentiality is protected by law.
6. State law mandates that suspected child abuse be reported to the Department of Health and Welfare and/or the police. All program staff are responsible for staying abreast of such reporting requirements of their respective jurisdiction and shall always comply with mandated procedures.
7. If a program worker receives information indicating that a student or volunteer may be dangerous to him/herself or to others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or a report to the law enforcement authorities.
I have read and understand the above document which states The Mentoring Network’s policy with respect to confidentiality of student and volunteer records. I agree to program participation under the conditions it sets forth.