FBPFY Mentor Application

FORT BEND COUNTY JUVENILE PROBATION DEPARTMENT
122 Golfview Richmond, TX. 77469 Phone: 281-633-7317 Fax: 832-471-1839
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Full Name*

First NameMiddle NameLast Name
Maiden Name (If applicable)
Previous Name(s) (If applicable)
MonthDayYear
Birth Date
SSN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Previous Address (Past 10 Years)
Cell Phone
Home Phone
Email Address
Gender
Race
Ethnicity (Hispanic or Non)
How did you hear about us?
Why do you want to be a mentor?

List any current or past mentor/ volunteer involvement

	Organization	Type of work
1.
2.
3.
4.

Please list any special skills or talents you may want to contribute:
Do you speak a language other than English?

YesNo
If yes please specify
Do you own, or have reliable use of a car?

YesNo
Do you hold current liability insurance?

YesNo
I certify that I am currently maintaining Motor Vehicle Liability Insurance, as required by Texas Law. In the event such insurance is terminated or canceled for any reason, I agree to promptly notify you in writing. I further agree not to operate a motor vehicle in connection with my activities as a mentor until such insurance is reinstated. **Please include a copy of your insurance card you keep in your vehicle and driver’s license with this application.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Do you currently have any family member involved in the juvenile probation department? If yes, who?
Have you ever been involved in a misdemeanor or felony court action? If yes, what and when?

Provide three references below, other than family members:

	Name	Daytime phone	Email
1.
2.
3.

SIGNATURES FOR ALL APPLICANTS REQUIRED BELOW
I authorize the verification of all information in my volunteer application. I give my permission for a criminal record check of my background and fingerprinting to be completed and reviewed by staff. I agree to provide additional information as needed to process my application and determine my suitability for the program.

I understand and agree that any omission, false statement, misleading statement or answer made by me on my application, any supplements to it or in any request for information from the Juvenile Department is cause for my dismissal from the mentor program. I understand that my information will be treated confidentially and only released if required by law.

I understand that I will be volunteering my time and will not receive any monetary compensation for my participation as a Program Mentor.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
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Include a copy of your vehicle insurance card Cancelof
Browse Files
Include a copy of your driver's license Cancelof

FORT BEND COUNTY JUVENILE PROBATION DEPARTMENT
122 Golfview Drive, Richmond, Texas 77469
(281) 633-7400
Executive Director
Chief Juvenile Probation Officer
Matthew "Kyle' Dobbs
JUVENILE BOARD
HON. JEFF McMEANS
Juvenile Board Chair
HON. CHRISTOPHER MORALES
HON. JULI MATHEW
HON. TONI WALLACE
HON. TEANA WATSON
HON. SHERMAN HATTON
HON. FRANK FRALEY
HON. O’NEIL WILLIAMS
HON. WALTER ARMATYS
HON. BRENDA MULLINIX
HON. MAGGIE JARAMILLO
HON. JAMES H. SHOEMAKE
HON. ROBERT ROLNICK
HON. DAVID PERWIN
HON. K.P. GEORGE
July 2, 2019

Sexual Misconduct, Abuse, Neglect, and Exploitation Disclosures

Pursuant to the Texas Administrative Code Chapter 344 and the Prison Rape Elimination Act Chapter 115, the Fort Bend County Juvenile Probation Department is prohibited from employing or enlisting the services of any applicant, intern, volunteer or contractor who:

A. has engaged in, been convicted of, or been civilly or administratively adjudicated for, sexual abuse in a confinement facility, juvenile facility, or other institution,
B. has been convicted of engaging or attempting to engage in unlawful sexual
activity in the community.
C. has engaged in, been convicted of, or been civilly or administratively adjudicatedfor, committing or attempting to commit abuse, neglect, or exploitation in a confinement facility, juvenile facility, or other institution or,
D. has been convicted of engaging or attempting to engage in abuse, neglect, or
exploitation in the community.

Therefore, the Fort Bend County Juvenile Probation Department will consult numerous entities as part of a background check including, but not limited to, state child abuse registries (where available), state and federal law enforcement databases, and previous employers in order to ensure that all employees, interns, volunteers, and contract service providers meet these requirements.

Employees, interns, volunteers, and contract service providers of the Fort Bend County Juvenile Probation Department have the affirmative duty to disclose such misconduct as a condition of employment or contractual agreement. Failure to disclose such misconduct, material omissions related to such misconduct, or the provision of false information related to such misconduct shall render the applicant ineligible for employment or to perform services for the Fort Bend County Juvenile Probation Department or be grounds for termination. Disclosures which indicate a crime may have been committed may require the Fort Bend County Juvenile
Probation Department to notify law enforcement and other appropriate entities.

Please address the following statements and disclosures by entering your initials in the appropriate blank for each statement and disclosure.
I affirm that I am eligible for employment or the provision of services based on the prohibitions stated on page 1, subsections A through D. I understand that I have a conditional offer of employment contingent on the findings of a background check. I understand that my conditional offer of employment will be rescinded if prohibited misconduct is discovered.
Initials*
Have you ever been convicted of or pleaded “guilty” or “no contest” to a felony or misdemeanor as an adult or juvenile? Include deferred probated adjudications as well as convictions that have been set aside.*

YesNo
Are you currently charged with (indictment or official criminal complaints by county or district court) a felony or misdemeanor?*

YesNo
Have you ever been or are you currently being investigated for allegedly abusing, neglecting or exploiting a child, an elderly person or a person with disabilities?*

YesNo
Have you ever had a certification Suspended (temporarily or permanent), received a Certification Probated Suspension, or Certification Revoked for allegedly abusing, neglecting or exploiting a child, an elderly person or a person with disabilities?*

YesNo
Please explain any disclosures answered in the affirmative. Be sure to include all applicable dates, times, locations, and involved parties. (Type N/A if not applicable)*
First NameLast Name
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Should be Empty:

SIGNATURES FOR ALL APPLICANTS REQUIRED BELOW