Thankyou Foryourinterestin Becoming Amentorfora Cadetinthealaskamilitaryyouthacademy.Spending

DepartmentofMilitaryand

VeteransAffairs

AlaskaMilitaryYouthAcademy

P.O.Box5727JBER,AK99505-0727Main:907-428-7306Fax:907-428-7380

DearMentorApplicant,

Thankyou foryourinterestin becoming aMentorfora CadetintheAlaskaMilitaryYouthAcademy.Spending timewith a young adult,ashe/shemakesimportantlifedecisionsisoneofthemostimportantthingsyoucan dotohelp.Informationaboutour program isavailableat

Tobeacceptedto theAcademy,each CadetisREQUIREDtohaveaMentor.Mentorsmustbe21 or older,samegenderasCadet,notan immediatefamily member(notmom,dador step-parent),and notliving in thesamehomeastheCadet.

PleasegivethisapplicationtoyourCadetto takewiththem totheirinterview-OR-you mayfaxormailthefully completedMentorApplication with thetworeferencesforyou,to ourofficeassoonaspossible,hopefullywithin oneweekofreceiving thisletterand nolaterthan thestartof thecycle.

Youwillberequired tocompleteaMentorTraining class,eitherin person,via internetordistancelearning packet.You willbenotifiedof thedatesof thesein-persontrainings for thosementorsthatarein reasonabledriving distanceof Fairbanksand Anchorage.Ourprimaryformofcontactwith mentorswill be via e-mail communication.

Platoon / MentorCoordinator / Phone / e-mailFax: 907-428-7385
AllPlatoons / Deb Morton / 907-428-7337 /

If you haveanyquestions,pleasecontactoneof theAMYACoordinatorsatthenumber(s)above.

□MentorApplication

□Releaseof Information

□MentorJob Description (Signed)

□MentorQuestionnaire

□Stateof AlaskaConfidentiality of Information Acknowledgement

□VolunteerServiceAgreement

□MentorReference(completed**)

Thankyou forvolunteeringto mentorayouth!

**Please givethe 2enclosedreferenceformsaboutyou,atthe endofyour application,to
a neighbor, coworker, ora friendtofillout.Thenplease returnthem withyour application
toyour CadetortoanAMYA Coordinator bymailtoAMYA-MentorPOBox5727JBER,AK
99505orfaxto907-428-7385**

AMYAMentorApplication- Welcome andChecklist1

MENTOR APPLICATION/Release ofInformation forBackground Check

PleasePrintNEATLYthefollowinginformation

(Full LegalName) LastName / FirstName / FullMiddleName / Date ofBirth / Last4 ofSSN / Gender
Drivers License #(required) / DL StateofIssue / Maiden Name orOtherName Used: / MaritalStatus / Spouse’s Name
CurrentMailingAddress (Street/Apt#/PO Box) / City / State / Zip Code
CurrentResidentialAddress / City / State / Zip Code
Ifnotatcurrentaddress forthepast5 years,please listFormerAddress / City / State / Zip Code
Ethnicity(forstatisticalpurposesonly) please circle
Asian/PacificIslanderWhiteHispanicBlackAlaskaNative/NativeAmericanOther:Specify
E-mailAddress (required) / Home Phone Number / CellNumber / Fax Number
NameofCadet/Youth you will be Mentoring(pleaseleaveblankityou arevolunteeringto Mentoryouth as needed)
CurrentEmployer’s Name / Occupation / Length ofEmployment / WorkPhone Number
Military Service(circlethosethatapply)
ActiveReserve
RetiredPastServiceOther:specify_ / Branch (circlethosethatapply)
ArmyCoastGuard
AirForceMarines
ARNGNavy
ANG / Rank / DoyoucurrentlyhaveaccessorvalidID foraccessto JBER?
YESNO
Do you have yourown transportation?
YESNO
Doyouhavecarinsurance?YESNO
InsuranceCo:_
Whileparticipating intheAlaskaMilitary Youth Academy activities,picturesmaybetaken. I grantpermissiontouse mynameand pictureforthepurposeof promoting,recruiting,training or newsstories oftheAlaskaMilitaryYouthAcademy. Yes No

Explain anycurrentoffenses onyour driving record: Haveyoueverbeen convicted ofa CriminalOffense(found guiltyor pleaagreementtoany misdemeanororfelony

offense)?No

Yespleasegivefulldetailstoincludedate(s)and location(s) (useanothersheetifneeded)

AMYAMentorInformation/Confidentiality/Release2

MENTOR JOBDESCRIPTION

The Mentorservesasarole modeland adultfriend toa Cadetduring the Residentialand PostResidential Phases.

Working Relationship:

ReportstotheAlaskaMilitaryYouth Academy(AMYA)Coordinator

Responsibilities:

Committospending12 monthsin aftercare(post-residentialphase-the12 monthsfollowing thecadet’sgraduationfrom theresidentialportion of theprogram).Weeklycontactwith Cadet,byletter,phonecall,or in person.Minimum of4hourscontactpermonthor4contactspermonth(preferably2ofwhich arefacetoface).Totalcommitmentis18 monthsfrom thestartoftheprogram.

Return completedmaterialspromptly.

Completerequiredtraining(s).

Committo makeweeklycontactwith Cadet,by mail,orin personduring the5 month residentialphase.Minimumof 4 hourscontactper month, or4 contactsper month(preferably2ofwhich are facetoface).

Discussand assist Cadetwith setting short,med and long-termgoalsleading to theCadet’sPost-ResidentialActionPlan(P-RAP).

Observeprogram policiesand guidelines formentors.DiscussviolationswithAMYACoordinator.

ReferCadetto communityresourcesifandwhen needed.

Participateinmentorvisitationsand relevantactivities.(Pleasenotethatifyou arenotin reasonable drivingdistancetoJBER(JointBaseElmendorf-Richardson),you willnotberequiredto travelfortheseevents.)

Sharein informaland fun activitieswith Cadet.

Communicateatleastmonthlywith AMYACoordinator.(thisincludesmonthlyreportsinthe12 month post-residentialphase)

Promptlyinform AMYACoordinatorofanyneedsor problemsthatmayariseinCadet’slife.

***Mentorsoutside reasonabledriving distancetoAnchoragearenotrequiredto traveltoJBER,howevershould bewriting theircadet ore-mailing them hiletheyarein theresidentialportionof theprogram.***

MentorApplicantPrintedNameMentorApplicantSignatureDate

AMYAMentorApplication-MentorJobDescription3

MENTOR QUESTIONNAIRE

MentorName(print)

CadetName

Thisis a shortquestionnairethatispartoftheprocessfor screeningthementors.

In orderto knowyoualittlebitbetter,wehavea fewquestionsthatwewould liketoask you.Weappreciateeveryone’sindividualitiesand strengths.Thereisn’tanyrightorwrong answers; wejustwantyouto behonestand straightforward.

1.Whatisyourrelationshipwith theCadet?

2.Whoreferred you tobeamentorfortheAlaskaMilitaryYouth Academy?

Asyou areaware,thisis a tobacco,alcoholand drug freeprogram.Someofour cadetshavehad problemsin thepastwith thesesubstances.

3.Do you havea personalhistory ofdrug oralcoholabuse?Haveyou experiencedproblemswith drugs oralcohol,forexamplewith a family member?Ifso,howhaveyoudealtwith it?

4.Whatisyouropinion regarding underagedrinking and drug use?

5.Willyou insistthattheCadetrefrain from smoking,using tobacco,drugsor alcohol?

6.Willyou insistthattheCadetremainwithyouatalltimeswhileonpass?

7.Whatareyourhobbiesor interests?

8.Whatlanguagesdoyou speak?

9.Do you attend church?NoYesWhatchurchdoyou attend

AMYAislocated on JBER(JointBaseElmendorfRichardson),asecuremilitary installation.Youmusthavea MilitaryID,DODID,DBIDS,orothermilitaryissued IDcard toaccesstheinstallation. Ifyou do nothave access,please providethe following information;

Driver’sLicense/StateIDNumber:

Stateof Issue:

MentorApplicantPrintedNameMentorApplicantSignatureDate

1.I,

STATEOFALASKA

ConfidentialityofInformationAcknowledgment

, amanemployee,contractor,volunteer ofthe

9/17/18

Department ofMilitaryand Veteran’sAffairs/Alaska MilitaryYouthAcademy.Iunderstandthat,in performingmydutiesImayhave access to confidentialinformation about state employees orentitiesthat do businesswith the state.Iagree thatIwill not discuss,disclose, orcause disclosureofanysuchconfidentialinformation to anyone who does not have abusiness needand a legalright to knowthe information.

2.I willhandle andstore confidentialinformation inaccordance withstateanddepartmentpolicy.

3.I acknowledge thatI couldsuffer disciplinaryaction, includingdischarge fromstate employment,and, in certaincircumstances,facecriminalpenaltiesfor revealingconfidential information tosomeone whodoes not haveboth a business needand a legalright to knowthe information, or formisusingconfidentialinformation.IfIdo not know whethera personrequestingconfidentialinformation is entitled toreceive the information,Iwillconsultmysupervisor.

Examples of confidentialinformationcoveredbythis acknowledgement:

-PersonnelinformationcoveredbyAS 39.25.080 (seepage 2),as well asinformationsuchassocial securitynumbers,birthdates,home addresses/phone numbers, leavebalances,personnel actions, investigations,grievances,applications,appeals, or anyother

personnelmatter,and other state businessthat is confidentialunder statute.

-Allinformationthat is confidentialbylaw, includingbut not limited to taxmattersandbeneficiaryprograms.

-Informationthatbyits nature must be secured to prevent harm to the state orits businesspartners, includingbut not limited to creditcardinformationandvendor taxinformation.

CertificationStatement:By signing below I acknowledge that I have read and understand theinformationincluded in thisacknowledgement.

PrintedNameSignatureDate

9/17/18

AlaskaStatute39.25.080

Sec.39.25.080.Personnelrecordsconfidential;exceptions.

(a)Statepersonnelrecords,includingemploymentapplicationsandexaminationandotherassessmentmaterials,areconfidentialandarenotopentopublicinspectionexceptasprovidedinthissection.

(b)Thefollowinginformationisavailableforpublicinspection,subjecttoreasonableregulationsonthetimeand mannerofinspection:

(1)Thenamesandpositiontitlesofallstateemployees;

(2)Thepositionheldbyastateemployee;(3)Priorpositionsheldbyastateemployee;

(4)Whetherastateemployeeisintheclassified,partiallyexempt,orexemptservice;(5)Thedatesofappointmentandseparationofastateemployee;

(6)Thecompensationauthorizedforastateemployee;and

(7)WhetherastateemployeehasbeendismissedordisciplinedforaviolationofAS39.25.160(l)(interferenceorfailuretocooperatewiththeLegislativeBudgetandAuditCommittee).

(c)Astateemployeehastherighttoexaminetheemployee'sownpersonnelfilesand mayauthorizeotherstoexaminethosefiles.

(d)Anapplicantforstateemploymentwhoappealsanexaminationscoremayreviewwrittenexaminationquestionsrelatingto theexaminationunlessthequestionsaretobeusedinfutureexaminations.

(e)Inadditiontoanyaccesstostatepersonnelrecordsauthorizedunder(b)ofthissection,statepersonnelrecordsshallpromptlybe madeavailableto thechildsupportservicesagencycreatedinAS25.27.010orthechild support

enforcementagencyofanotherstate.Iftherecordispreparedormaintainedinanelectronicdatabase,itmaybe

suppliedbyprovidingtherequestingagencywithaccesstothedatabaseoracopyoftheinformationinthedatabaseandastatementcertifyingitscontents.Theagencyreceivinginformation underthissubsectionmayusetheinformationonlyforchildsupportpurposesauthorizedunderlaw.

AlaskaStatute39.25.900

Sec.39.25.900.Penalties.

(a)Apersonwho willfullyviolatesaprovisionofthischapterorofthepersonnelrulesadoptedunderthischapterisguiltyofamisdemeanor.

(b)Astateemployee whoisconvictedofa misdemeanorunderthischapterorthepersonnelrulesadoptedunderthischapterimmediatelyforfeitstheemployee'sofficeorposition.

TheAlaskaWhistleblowerAct

TheAlaskaWhistleblowersAct(AS39.90.100—39.90.150)prohibitspublicemployersfromdischarging,threatening,orotherwisediscriminatingagainstemployeesforreportingmattersofpublicconcerntoapublicbody.

Thewhistleblowerprotectionextendstothosewhohave made—orareabouttomake—reportsonmattersofpublicconcern,aswellasthosewhoparticipateincourtactions,investigations,hearings,orinquiriesonmattersof

publicconcern.

A"matterofpublicconcern"meansaviolationofstate,federal,ormunicipallaw,regulation,orordinance;adangertopublichealthorsafety;grossmismanagement,substantialwasteoffunds,orclearabuseofauthority;amatterthattheofficeoftheombudsman hasacceptedforinvestigation;orinterferenceorfailuretocooperatewiththeLegislativeBudgetandAuditCommittee.

A"publicbody" meansanofficeroragencyofthe federalgovernment,thestate,apoliticalsubdivisionofthestate,

apublicorquasi-publiccorporationorauthorityestablishedbystatelaw,ortheUniversityofAlaska.Consequently,whistleblowerprotectioncouldapplytoastateemployee'sreporttohisorherownemployer.

Whistleblowerprotectionappliesonlywhenthereportingpersonreasonablybelievesthattheinformationreportedisorisabouttobecomeamatterofpublicconcernandthepersonreportsthe matteringoodfaith.Theprotectiondoesnotapplyifthe matterofpublicconcernistheresultofthereportingperson'sownconduct,unlessthereportingperson'semployerrequiredthatconduct.

STATEOFALASKAVOLUNTEER SERVICE AGREEMENT

ThisAgreementisenteredintobetweentheStateofAlaska,DepartmentofMilitary&Veteran’sAffairs (State),andDivision

of Alaska MilitaryYouthAcademy,further referred toasAMYAAnd

whoseaddressis.

WHEREAS,theVolunteerdesirestoparticipateasanunpaidworkerfrom:to:(providedates)inthefollowingprogramAMYA Mentoring (Program)at AMYA Campus,Events, orMentor/Cadet Related Activities (Division,facilityorlocation);performingthefollowing

activities AMYA MentoringActivities as outlinedinthe AMYAMentoring Trainingand MentorJobDescription

alongside,butnotdisplacingStateemployeesand,WHEREAS,theStatedesirestoallowtheVolunteertoparticipateinsaidProgram,

NOW,THEREFORE,thepartiesagreeasfollows:

TheVolunteeragreestoparticipatewithoutcompensationforhis/heractivitiesintheProgramunderthedirectsupervisionofStateemployee Deborah Morton,AMYARPM Supervisor,phone #:907-428-7337or (Supervisor).

•ForthedurationoftheVolunteer'sparticipationintheProgram,theStateagreestoprovidetotheVolunteermedicalcoverageanddisabilitycompensation,inamountscomparabletothataffordedemployeesundertheAlaskaWorkers'CompensationAct(AWCA),iftheVolunteersuffersinjury,illnessordeaththatarisesoutof,andoccurswhileactingwithinthe courseand

scopeofperformanceofhis/hervolunteerduties. Itis agreed thatweeklycompensationfordisabilityor deathwill be basedon theminimumrateofcompensationunderAS23.30.175.It isagreed thatcompensationor medicalcoveragewill notbeprovidedwhenthevolunteermaybeeligibleforcoveragebyanyotherhealthordisabilitypolicy,insurance,paymentor benefit,(inc.Medicaid,Medicare,SocialSecurity,orpension)or workers'compensationcoveragebyanotheremployer.Disputesregardingpaymentofcompensationand medicalbenefitsunder thisagreementare agreed tobedecidedbytheAlaskaWorkers’CompensationBoardwithoutstipulatingto the Board’sjurisdiction.TheStateisnotsubjecttoAWCApenalty,interest,SIF,or otherpaymentinregardtotheVolunteer.

•TheStateagreestodefend,indemnify,andholdharmlessthe Volunteerin thesamemannerand to the same extenttheState protectsitsemployeesfromanyclaim,demand,suit for propertydamagesor personalinjuryincludingdeathallegedlycausedbytheVolunteer'sactivitiesiftheVolunteer:a)atthe time ofthe occurrencewas actingingoodfaithwithinthecourseandscopeofhis/hervolunteerdutiesinaccordancewiththedirectionsoftheSupervisor;b) theVolunteerprovidesimmediate noticeto the Stateofanyclaim;andc)theVolunteercooperatesin thedefenseanddoesnotstipulatetoanyjudgmentor settlementwithoutthe State’sapproval.

•TheVolunteerunderstandstheStatedoesnotinsurelossor physicaldamagetoitsemployee’spersonalvehicle,equipment,or otherpersonalpropertyused whileperformingstatework;nor will theStateprovidepropertyinsurancecoveragefor lossor physicaldamagetoanyVolunteer’spersonalvehicle,equipment,orotherpersonalpropertyused whileperforminghis/hervolunteerduties.

•In considerationofthe benefitsreceivedfromparticipationin theProgramandtheprotectionofferedbythisAgreement,theVolunteer:1)acceptsthe remedyprovidedbythe State,and disputeresolutionbytheAlaskaWorkers'CompensationBoard,ashis/hersolelegalremedyfromthe StateiftheVolunteersuffersinjury,illnessordeatharisingout of,and occurringwhile actingwithinthe courseandscopeof, his/hervolunteerduties;2) transfershis/herrighttorecoverfromothers whomaybe responsibleforthe injury,illness,or deathto the Stateand/oritsassignsuponpaymentofcompensationor medicalexpensesbythe State;and3)agreestocooperateand todoeverythingnecessarytoenabletheStateand/oritsassignsto enforcethe righttorecoverfromothers.

TheAgreementiseffectiveonthedaywhensignedbythepersondesignatedbelowastheProgramDirectorandfiledwiththeDivisionofRiskManagement.

TheVolunteeracknowledgeshe/shehasreadthisAgreement,understandsitandagreestobeboundbyitsterms.

SIGNEDbyVOLUNTEER:XDATE:

HomeTelephoneNumber:ActivitySiteTelephoneNumber:907-428-7325(AMYATLC)

ProgramSupervisor: DeborahMorton Title: RPM Supervisor TelephoneNumber: 907-428-7337

ProgramDirector: BobRosesTitle: AMYADirector TelephoneNumber: 907-428-7306 WillVolunteerbeTraveling? YESX NO IfYES,indicatemodewith“S”forState-ownedor“P”forPersonally-owned:

VehiclePPlaneBoatATV

Distribution:

Copy-Department/ProgramCopy–VolunteerCopy–ivisionofRiskManagement465-2181Revised03/16/12

Mentors-pleaseinsertyournameand providethistosomeonewhocan be areferenceforyou.

MentorApplicant’sName

Mentor ReferenceForm

Theperson namedabovehasapplied tobeavolunteer mentorwiththeAlaskaMilitaryYouthAcademy. He/sheisbeing consideredforamatch inaone-to-onerelationshipwithoneofour Cadets.Theinformation receivedis kept inconfidence.Formoreinformation aboutourprogram pleasegoto 907-428-7339.

Howlong haveyouknowntheapplicant?

Inwhatcapacity?

Doestheapplicantworkwellwithothers? Doestheapplicant have a good home relationship? Doeshe/shehavea tendencyto over-commitorget tooinvolved?

Please ratethe volunteeron the questionsbelow: / Excellent / Average / Poor
Compassionforthosein need?
Concern foryoung people?
Maturityand stability?
Abilitytorespectotherswith differing viewsand valuesfrom one’sown?
Skillfulnesstoexpressan opinion in thefaceofopposition?
Responsibilitytouseconfidentialinformation appropriately?
Abilitytoremainobjectivein crisisand conflictsituation?
Abilitytoproblem solve and reach decisionsindependently?
Opennesstolearning?
Verbalcommunication skills?
Writtencommunication skills?
Proficiency tocarryoutassignmentsin duetime?

Do you haveany concernsaboutthesuitabilityof theapplicant’sability toworkwith ourCadets?

ReferencePrinted NameDate

ReferenceSignaturePhone

ReferenceEmailAddress:

Wouldyou liketo volunteer to beamentorfortheAlaskaMilitary Youth Academy?

No _YesNeedmoreinformation

Reference: Pleasereturn to AMYA-MentorPOBox5727JBER,AK99505–or-fax to 907-428-7385-or-emailto

Mentors-pleaseinsertyournameand providethistosomeonewhocan be areferenceforyou.

MentorApplicant’sName

Mentor ReferenceForm

Theperson namedabovehasapplied tobeavolunteer mentorwiththeAlaskaMilitaryYouth Academy. He/sheisbeingconsideredforamatch inaone-to-onerelationship withoneofour Cadets.Theinformation receivedis kept inconfidence.Formoreinformation aboutourprogram pleasegoto

Howlong haveyouknowntheapplicant?

Inwhatcapacity?

Doesthe applicantworkwellwithothers? Doestheapplicanthavea good homerelationship? Doeshe/shehavea tendencyto over-commitorget tooinvolved?

Please ratethe volunteeron the questionsbelow: / Excellent / Average / Poor
Compassionforthosein need?
Concern foryoung people?
Maturityand stability?
Abilitytorespectotherswith differing viewsand valuesfrom one’sown?
Skillfulnesstoexpressan opinion in thefaceofopposition?
Responsibilitytouseconfidentialinformation appropriately?
Abilitytoremainobjectivein crisisand conflictsituation?
Abilitytoproblem solve and reach decisionsindependently?
Opennesstolearning?
Verbalcommunication skills?
Writtencommunicationskills?
Proficiency tocarryoutassignmentsin duetime?

Do you haveany concernsaboutthesuitabilityof theapplicant’sability toworkwith ourCadets?

ReferencePrinted NameDate

ReferenceSignaturePhone

ReferenceEmailAddress:

Wouldyou liketo volunteer to beamentorfortheAlaskaMilitary Youth Academy?

No _YesNeedmoreinformation