Sierra Vista Child & Family Services Mentor Application

Mentor Information

First Name *This question is required.

Last Name *This question is required.

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Driver’s License Number *This question is required.

Home Phone Number *This question is required.

Cell Phone Number *This question is required.

Work Phone Number

Email Address *This question is required. This question requires a valid email address.

Gender

Race/Ethnicity

Please enter an 'other' value for this selection.

The minimum age requirement to be considered for a mentor role is 18 years of age. Please select the following box acknowledging that you meet the requirement: *This question is required.

Yes, I am at least 18 years old.

Education

Space Cell	School Attended	Degree
School 1:	School 1:: School Attended	School 1:: Degree
School 2:	School 2:: School Attended	School 2:: Degree

List any license, degree or certificate you may hold that is not listed above:

How were you recruited as a Mentor? (Mark only one) *This question is required.

Volunteer Experience & Community Program Involvement: Please describe program, duties, when & why you left:

Personal Data:

Are you currently awaiting trial for any criminal offenses?

*This question is required.

If yes, please explain:

Have you or any members of your immediate family received services from Sierra Vista Child & Family Services during the past 5 years?

*This question is required.

If your answer is yes, you may not be eligible to volunteer.

Interests:

Please check and list any special interests, talents or skills that you would like to share: *This question is required.

Employment History:

Current Employer

Street Address

Apt/Suite/Office

City

State

Zip

Date of Hire This question requires a valid date format of MM/DD/YYYY.

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Job Title

Supervisor

Describe past employment/position(s) held:

Space Cell	Employer	Job Title	Dates of Employment	Supervisor	Contact Phone
1:	1:: Employer	1:: Job Title	1:: Dates of Employment	1:: Supervisor	1:: Contact Phone
2:	2:: Employer	2:: Job Title	2:: Dates of Employment	2:: Supervisor	2:: Contact Phone

References: List two people who may be contacted for a personal/professional reference:

Reference 1: *This question is required.

Name

Relationship

Street Address

Apt/Suite/Office apt/suite/office OR "N/A"

City

State

Zip

Phone Number

Reference 2: *This question is required.

Name

Relationship

Street Address

Apt/Suite/Office apt/suite/office OR "N/A"

City

State

Zip

Phone Number

Certification:

I hereby certify I have not knowingly withheld any information that might adversely affect my chances for volunteering and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand any omission or misstatement of material fact on this application or on any document used to secure a volunteer position shall be grounds for rejection of this application or for immediate discharge if I am volunteering, regardless of the time elapsed before discovery.

*This question is required.

Clear

Signature of

I hereby authorize SVCFS to thoroughly investigate my references, work record, education and other matters related to my suitability for volunteering. I further authorize the references I have listed to disclose to the organization any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release SVCFS, my former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of, or in any way related to, such investigation or disclosure. *This question is required.

Clear

Signature of

I understand nothing contained in this application or conveyed during any conversation or interview is intended to create an employment contract between me and the organization. In addition, I understand and agree if I become a volunteer, my position will not be for any specified period of time and may be terminated at any time, with or without prior notice, at the option of either myself or the organization. No promises or representations contrary to the foregoing are binding on the organization unless made in writing and signed by the CEO of SVCFS. The fact that I may complete a specified probationary period will not change this. The Executive Director reserves the right to refuse any applicant participation. *This question is required.

Clear

Signature of

Signature of Applicant: *This question is required.

Clear

Signature of

Today's Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Sierra Vista Child & Family Services Mentor Application

Welcome