Mentor Application

Mentor Application

Name ______Date of Birth ______

First Middle Last Social Security # ______

(SSN and DOB required for background check)

Home Address ______

Street City, State Zip Code

Email ______Cell ______Work______

Best Way to Contact You? (circle one) Home Cell Work Email Mail

Age ______Gender Male Female Unspecified

Mentor’s Race Hispanic/Latino American Indian/Alaskan Native White/Caucasian

Black/African American Asian Native Hawaiian/Pacific Islander Other

Marital Status Single never married Married Divorced Separated Widowed

Emergency Contact ______Phone number ______

Highest Education Level ______

Employer ______Occupation ______

Contact You At Work? Yes No Hours ______How Long Employed? ______

Volunteers must provide documentation along with this application of having a valid driver’s license and auto insurance to participate in KLF mentoring programs and to transport a youth in any vehicle you are operating.

State and DL # ______Expiration Date ______Have Auto Insurance? Yes No

Do you have a criminal record? Yes No If yes, please explain the details of such record (offense, date, location, circumstance, outcome): ______

What type of mentoring are you interested in? 1:1 1:1 as a couple/family group both

Please share some of your primary hobbies/interests: ______

______

What is your motivation for volunteering as a mentor through the Knoxville Leadership Foundation? ______

______

References

Name / Address / Telephone Numbers / Email Address / Relationship to You
Home:
Cell:
Home:
Cell:
Home:
Cell:
Home:
Cell:

Please list four references that have known you for more than a year, are not a member of your immediate family, and preferably have observed you with children. Please print their name, telephone numbers (daytime, cell, home), and relationship to you.

Community Involvement

List all community and youth organizations you are involved in. (For example, civic organizations, church involvement, club memberships, professional associations, nonprofit boards, volunteer groups, etc.)

Organization Name / Position Held / Length of Time Involved / May We Contact Them to Recruit Mentors?

Mentoring Experience

Have you ever been, or applied to be, a mentor? Yes No Where and When? ______

How did you hear about KLF’s Mentoring Initiatives? ______

Referrals

Is there anyone you know who might be interested in becoming a mentor? Yes No

If yes, please provide their name and contact information (email or phone number): ______

Knoxville Leadership Foundation The Regas Building 318 N. Gay St., Suite 210 Knoxville, TN 37917

tel:865.524.2774 fax: 865.525.4213 www.klf.org

STATEMENT OF AGREEMENT

I understand that:

1)  The references I listed may be contacted by mail, e-mail or telephone;

2)  I am in no way obligated to perform any volunteer services;

3)  The information I provided may be used to conduct a background check, to include driving records check, criminal background and sexual offender registry checks and other records where required by local, state, or federal law for volunteers working with youth;

4)  I will provide applicable documentation before transporting youth in the vehicle I operate, which includes a valid driver’s license and current automobile insurance;

5)  The Knoxville Leadership Foundation is not obligated to match me with a youth;

6)  Other youth organizations where I have worked or volunteered may be contacted as references; and,

7)  As part of the enrollment process, I will be asked to provide additional personal information prior to any recommendations for assignment.

Please read this carefully before signing:

The Knoxville Leadership Foundation appreciates your interest in becoming a mentor to a youth individually or in a group setting. By signing below, you attest to the truthfulness of all information listed on this application.

I understand that KLF Mentoring Initiatives include community-based mentoring programs that match at-risk youth with mentors for four to six hours per month for one year. If selected, I will follow the rules of the program and be a dedicated mentor. I agree to the time commitment of meeting one-on-one with a child or in a group setting for four to six hours per month for the duration of one year.

______

Applicant’s Signature Date

CONFIDENTIALITY POLICY

The Knoxville Leadership Foundation respects the confidentiality of mentee and mentor records and, with the exception of situations listed below, shares information about mentees and mentors only among the agency professional staff.

All records are considered the property of the agency and not the agency workers, mentees, or mentors themselves. Records are not available for review by the mentees or mentors.

1.  Information will be released to other individuals or non-KLF organizations only with the mentee or mentor's written consent.

2.  Identifying information regarding mentees and mentors may be used in agency publications or promotional materials unless the clients or volunteer request otherwise.

3.  Information shall only be provided to law enforcement officials or the courts pursuant with a valid and enforceable subpoena.

4.  Information shall be provided to an agency's legal counsel in the event litigation or potential litigation involving the agency.

5.  State law mandates that suspected child abuse be reported to the Tennessee Department of Children's Services.

6.  If an agency worker receives information indicating that a mentee or mentor may be dangerous to himself or herself or to others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or report to the local law enforcement authorities.

7.  At the time a mentee or mentor is considered as a match candidate, information is shared between the prospective match parties. The information about the mentor may include such items as: age, sex, race, religion, interests, hobbies, marital and family status, sexual orientation, living situation, etc. Information about the mentee may include such items such as: age, sex, race, religion, interests, hobbies, family situation, etc.

I agree to program participation under the above conditions. I further agree that I will not share identifying confidential information with anyone outside the agency, including family, friends, or community members, without the written consent of the persons involved (parent/caregiver of a mentee, mentee, or the mentor). I also acknowledge that such information should be shared judiciously even within the ranks of the Knoxville Leadership Foundation, only with persons who have a specific need to know the information, and only in situations where others would not overhear such communication.

______

Mentor's Signature Date

DISCLOSURE AND AUTHORIZATION FORM

TO OBTAIN CONSUMER REPORTS

Please Read Carefully Before Signing the Authorization

DISCLOSURE

In considering you for employment/volunteering, or if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, Knoxville Leadership Foundation (“the Company”) may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc.

IntelliCorp Records, Inc. can be contacted by mail at 3000 Auburn Dr, Suite 410; Beachwood, OH 44122; or phone: 1-888-946-8355; or website: www.intellicorp.net.

For explanation purposes:

·  a “consumer report” is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and

·  an “investigative consumer report” is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act (“FCRA”).

Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

AUTHORIZATION

I have read and understand the foregoing Disclosure, and authorize Knoxville Leadership Foundation to obtain and rely upon consumer reports or investigative consumer reports in considering me for employment/volunteering and, if I am employed or become a volunteer, in considering me for subsequent promotion, assignment, reassignment, retention, or discipline. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in the employment decision about me.

I do ______do not______authorize you to contact my current employer for Employment and Reference Verifications

(This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.)

I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.

______

Printed Name

______

Applicant Signature Date

______

Parent or Legal Guardian Signature Date

(for searches conducted on minors under

the age of 18)

Personal Data

______

Last Name First Name Middle Name

Current Address Dates Lived Here

Addresses for the Past Seven Years: (include street, city, state, zip code) Dates of Residence:

Date of Birth Other Names Used (including maiden name) Years Used

Social Security Number Driver's License # State

Email address (may be used for official correspondence)

I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.

I certify that all elements of the personal data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.

______

Printed Name Applicant Signature Date

MEDIA RELEASE FORM

Knoxville Leadership Foundation (KLF) and its programs or various other media may choose to take pictures or videotape participants during events and activities. These images may be used for KLF displays, brochures, newsletters, archives, news releases, publicity and Web sites.

I hereby grant permission to Knoxville Leadership Foundation to take and reproduce photographs and videotapes for publication, including publication by news sources and other sources for all educational, trade, advertising and other purposes as determined by Knoxville Leadership Foundation.

______
Print Participant Name Signature Date

______
Printed Parent/Guardian Name Parent/Guardian Signature (If Minor) Date

Address: ______

City/State/Zip: ______

Knoxville Leadership Foundation The Regas Building 318 N. Gay St., Suite 210 Knoxville, TN 37917

tel:865.524.2774 fax: 865.525.4213 www.klf.org