Mentor Application

Personal Information
Name
First Last
Email
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
Current Employment Field
Do you consent to a background check?
Self Disclosure: Is there anything that would prohibit you from working with at-risk youth?
Please explain
Educational Background
Past Volunteer Experience
How did you hear about the mentorship program?
Mentor Specific
Have you previously been involved as a mentor or mentee in a mentoring program?
Please select
Program Name
Are you able and willing to commit to the time needed (contacting mentee weekly) to be a mentor?
What motivated, you to become a mentor and what do you hope to accomplish through being a mentor?
(List top 3 things)
What individual talents, skills, hobbies, and/or experiences (include background or significant struggles you have overcome) do you bring that could help positively impact youth transitioning out of foster care?
(List top 5)
Do you have previous experience working with at-risk youth?
Please explain
Do you anticipate any changes in the next year that may interfere with your ability to connect on a regular basis with your mentee?
Do you feel you are capable and willing to find common ground in differences with your mentee related to but not limited to personality, culture, religion, or sexual orientation?
Can and will you commit to providing a safe connection for your mentee (including but not limited to places, people, and activities you include them in)?
Please explain
Please select any words below that you feel describe your personality:
References
Reference #1 Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Relationship to Applicant
Reference #2 Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Relationship to Applicant
I certify that the information contained in this application is correct to the best of my knowledge.
Signature (type name)*
Today's Date*
MM slash DD slash YYYY
Confidentiality Agreement
I understand that I may hear, see, have access to and contact with confidential and private information, data, records, paper files, or computer files. Examples of this confidential information are: program participant information, business information belonging to Foster Arizona Housing Project and/or Keys to Success Program, vendor information, contracts, and financial files.

By signing, I agree to not use such information to benefit yourself or others. I agree to not disclose, divulge, or communicate such information to any person, firm, corporation or other entity other than Foster Arizona Housing Project. I agree to not copy, email, or further share or take such information outside approved channels of Foster Arizona Housing Project without prior knowledge and approval of the CEO of Foster Arizona Housing Project.

I also understand and agree that, in a volunteer capacity with Foster Arizona Housing Project, any violation of this Agreement or the policies identified herein is grounds for immediate termination of my volunteer role. I understand that any confidential or proprietary information I develop or work on as part of my volunteer position belongs to Foster Arizona Housing Project, not me. I understand that the terms of this agreement carry over even if my volunteer position with Foster Arizona Housing Project should end.
Signature (type name)*
Today's Date*
MM slash DD slash YYYY
Talent Release
For valuable consideration, the sufficiency and receipt of which is hereby acknowledged, I, the undersigned, agree as follows:
- I consent to the use of my name, voice, image, likeness, and any and all attributes of my personality, in, on or in connection with any film, audio tape, video tape, audio-visual work, photograph, illustration, animation, or broadcast, in any media or embodiment, now known or unknown, including, without limitation, all formats of computer readable media, produced by or for the benefit of Foster Arizona. I further consent to the use of my name, voice, image, likeness, and any and all attributes of my personality in any advertising or promotional material created or used in connection with Foster Arizona, and each such item of advertising or promotional material will be considered a "Work" for purposes of this agreement.
- I irrevocably assign to Foster Arizona(a) any and all claims of copyright I may have in and to Foster Arizona, and (b) the right to use, print, produce, publish, copy, display, perform, exhibit, transmit, broadcast, disseminate, market, advertise, license, transfer, modify, and create derivative works from Foster Arizona in any media or format, now known or unknown, matching the purposes of Foster Arizona. I waive any right to inspect or approve the content of Foster Arizona.
- I hereby release, discharge, and agree to hold harmless Foster Arizona, its legal representatives and assigns, all persons acting under its authority, and those for whom it is acting, from all claims, causes of action and liability of any kind, now known or unknown, in law or in equity, based upon or arising out of Foster Arizona or this agreement including, without limitation, claims of libel, slander, invasion of privacy, right of publicity, defamation, trademark infringement, and copyright infringement.
- I represent and warrant that I am over the age of eighteen (18) years, and that the authorizations and rights granted hereunder do not conflict with or violate the rights of any third party.
- This agreement will be binding upon my heirs, successors, representatives, and assigns.
Signature (type name)*
Today's Date*
MM slash DD slash YYYY

Personal Information

Mentor Specific

References

Confidentiality Agreement

Talent Release

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