Mentor Application

OURgems Mentor Application

Date

First Name

Last Name

Physical Address

City

Zip Code

Mailing address different from Physical address?

Yes

Mailing Address

City

Zip Code

Ethnicity

Gender

Male

Female

Date of Birth

Age

Home Phone

Cell Phone

Family

Single

Married

Divorced

Separated

Name of Spouse

Children

How did you find out about OURGEMS & OURGents

Mentor

Website

Board/Staff

Other

How long have you been a resident of Washington state?

What other states have you lived in during the last 10 years?

Employer Name

Employer Address

Address

City

State

Zip Code

Job Title

Education

Highschool Diploma

Yes

Year

GED

Yes

Year

College/Tech Study

Yes

Years attended

Degree/Certificate

Yes

Type of Degree

Military Service

Yes

Branch/Years Served

Mentor Screening Information

In order to process your application, we must conduct screening procedures including a complete background check. The information listed below enables the program to complete these checks.The organization will not disclose this information to any third party not involved in conductingthese investigations.

Would you agree to have us screen your name through federal and state criminal and sex offender registries?

Yes

Applicant’s Full Legal Name (required for background check)

First Name

Last Name

Middle Name

Social Security Number

Do you have a valid Driver’s License?

Yes

If yes

License Number

State

Expiration Date

1. Have you ever been arrested for a sex-related crime?

Yes

If "YES" explain the incident, specify the state and date in which it occurred.

2. Have you ever been convicted of a sex-related crime?

Yes

3. Have you ever been arrested for a crime involving force and/or minors?

Yes

If "YES" explain the incident, specify the state and date in which it occurred.

4. Have you ever been convicted of a crime involving violence or threat of violence?

Yes

If "YES" explain the incident, specify the state and date in which it occurred.

7. Do you have history of alcohol, drug, or substance abuse?

Yes

8. Have you ever been convicted of a crime, other than a minor traffic violation?

Yes

If "YES" what was the crime?

Date

9. Have you been arrested for a crime and are awaiting formal filing of charges or trial?

Yes

If "YES" what was the arrest for?

Current Status?

Release of Information: I hereby grant to the OurGEMS/OurGents youth mentoring organization, and appropriate law enforcement agencies permission to check my references and civil or criminal records to verify any information provided in this application. I understand my duties as a mentor to abide by the laws of the State of Washington and the laws and policies governing the preservation of confidential information.

By signing below, you ensure to the best of your knowledge, all information provided is true and accurate.

Mentor Signature

Sign here

Date

What's Expected of Me As A Mentor For OurGEMS/OurGents?

Attend a mandatory group visitation day and a mandatory training and orientation session. This training date will be posted on our website, or you will be notified of a scheduled training time via email.
Make a minimum commitment of one year with an optional opportunity to continue in the relationship on a long-term basis.
Be dedicated and dependable in trying to assist our youths in achieving success in their educational, social, and emotional development.
Engage in the relationship with an open mind. Base your relationship on respect for our youths, their families, and all cultural backgrounds.
Be on time for scheduled meetings. Notify the program coordinator if you are unable to attend the mentoring session.
Refrain from contacting or seeing mentees outside of the established parameters and supervised sites where the program takes place except when coordinated by OurGEMS/OurGents and parent/guardian have agreed in writing to off-site meetings.
Understand that while serving as a mentor for OurGEMS or OurGents, I may gain information that may be considered personal and/or confidential and should be treated accordingly. An improper disclosure to an unauthorized third partly could constitute a violation of Washington State law and make me subject to legal action. All records dealing with students/mentees must be treated as confidential.

Photo Release Statement:

I grant OurGEMS/OurGents and its agents permission to use photographic portraits, pictures, digital images or videotapes of me, or in which I may be included in whole or part, or reproductions in color or otherwise for any agency websites, publications, social media and/or promotional materials without payment or any other consideration.

Yes

By signing below, you ensure to the best of your knowledge, all information provided is true and accurate.

Mentor Signature

Sign here

Date

OurGEMS/OurGents reserves the right to accept or decline volunteers based on the information gathered. For reasons of confidentiality OurGEMS/OurGents will not share this information or reasons of denial with any other applicants

Volunteer Mentor Status: I also understand and agree I am not an agent, employee or representative of OurGEMS/OurGents in my capacity as a mentor, nor will I claim to be such a representative, officer or employee of OurGEMS/OurGents. I will not make any claim of right, privilege or benefit that would accrue to such an agent, employee or representative. I do not expect to receive any monetary wages for services rendered during the mentoring period and understand as a volunteer I am not covered for any injury, damage or loss suffered while acting in the capacity as a mentor. I understand that if I use my private motor vehicle in the course of traveling to my volunteer mentor duties, it is my obligation to obtain and maintain state required liability insurance to cover any accidents involving my vehicle and to maintain the appropriate legally required vehicle operator’s license. I further understand that it is my responsibility to obtain and maintain insurance policies for damage, loss or liability on all personally owned, leased, or rented equipment I use while performing as a volunteer mentor. OurGEMS/OurGents will not provide any liability or other insurance coverage.

Hold Harmless: The Mentor will hold harmless OurGEMS/OurGents and its board, volunteers and employees while performing their mentoring activity, from any and all costs, claims, judgments, and/or awards of damages (both to persons and/or property), which may accrue to or be suffered by any person(s), or property, arising out of mentoring activities. The Mentor agrees to and hereby does waive any and all claims for personal injury and damages or losses to property, including expenses or lost revenues, in connection with mentoring activities. In case any claim, suit or action is brought against OurGEMS/OurGents and its board, volunteers and employees, arising out of the mentoring activity, the mentor shall, upon notice of such claim, suit or action, defend the same at their sole expense and satisfy any judgment and/or award of damages. This indemnification and waiver shall survive the termination of this release

Mentor Signature

Sign Here

Mentor Typed Name

Date

If not signed, this application will not be accepted.

Mentor

Application

PROSPECTIVE MENTOR INFORMATION