Urban League of Broward County

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Mentoring

Description of Mentoring Program

Mentor Application

First Name	*
Last Name	*
Address	*
City	*
State	*
Zip Code	*
Phone #
Cell Phone #
Employer
Employer Address
Your Position
How long have you been in your current position
Can you be contacted at work?		Yes No
Work Phone Number
E-mail Address
Are you prepared to:
- Commit 1 yr to a mentee in our Mentor Connection program?		Yes No
- Commit 1 month to mentees in our BUYEP program?		Yes No
Please list the names, addresses, and telephone numbers of three persons you would like to use as references (please list only people you have known at least one year). Please provide an employer reference as one of your references. References may not be family members. However, it can be from a previous volunteer organization and/or friends.
Reference 1
First Name
Last Name
Address
City
State
Zip Code
Phone #
Relationship
Reference 2
First Name
Last Name
Address
City
State
Zip Code
Phone #
Relationship
Reference 3
First Name
Last Name
Address
City
State
Zip Code
Phone #
Relationship

Comments
Please Read The Urban League of Broward County appreciates your interest in becoming a mentor to a participant in our program. By checking the box marked "I agree" below, you attest to the truthfulness of all information submitted on this application. You agree to allow our program to confirm all information listed and to conduct all reference and background checks listed in this application. I have read and understand the Urban League of Broward County’s rules, regulations, and responsibilities for becoming a mentor. If selected, I agree to follow the rules of the program and be a dedicated mentor. I agree to a time commitment of a minimum of one hour per week, for a period of one year.
I Agree
Background Check Compliance we complete background checks including drug testing and criminal background check on the local, state and federal level on all volunteer applicants. All information requested in this section will be used for those purposes only, and will remain in strict confidence of our agency.
I give permission to conduct a background check as stated above.
Social Security #
Date of Birth -mm/dd/yy
Florida Driver's License #
Currently able to provide proof of valid auto insurance		Yes No
Volunteer Informed Consent/Confidentiality I, acknowledge and understand that I am not obligated if called upon to perform the volunteer services applied for herein; that URBAN LEAGUE OF BROWARD COUNTY is not obligated to assign or actively seek to assign me a volunteer position. I have given necessary information and permission to URBAN LEAGUE OF BROWARD COUNTY to complete all references and background checks required by the agency including drug testing and criminal background check on the local, state and federal level. I understand that the results of the background checks, as well as any other information pertaining to me including; written application, references, interview records, and any other records are from this date forward the property of URBAN LEAGUE OF BROWARD COUNTY. I understand that I may not review these records nor receive a copy of them and that the records will be kept confidential, accessible by Human Resource of URBAN LEAGUE OF BROWARD COUNTY only, unless subpoenaed by court order or reviewed for quality assurance purposes by accreditation organizations or agency funding sources. I understand that if I accept a volunteer position assigned to me, that URBAN LEAGUE OF BROWARD COUNTY or I may terminate my position at any time.
I agree with the Volunteer Consent/ Confidentiality Statement
Statement of Confidentiality As a volunteer employed with Urban League of Broward County, I understand that I may be aware of, witness, or be directly informed of sensitive and personal information about the young person I choose to mentor, or his/her family members. I agree to respect the confidence of my mentee(s), and not disclose confidential information except under the following circumstances as required by law: Disclosed threat of harm to self or others Disclosure of physical, sexual or emotional abuse or neglect I further agree to report any such disclosures or incidents IMMEDIATELY to representatives of Urban League of Broward County, and inform my mentee of the requirement to do so.
I agree with the Statement of Confidentiality
Media Release I hereby give Urban League of Broward County, their assigns, licensees and legal representatives the irrevocable right to use my name, picture, photograph, portrait, visual likeness or voice in all forms and media in all manners, including photo, film, audio and video representations, for non-profit, public purposes and I hereby waive any right to inspect or approve the finished product that may be created in connection therewith.I have read this release and am fully familiar with its contents.
I agree with the above media statement
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