Mentor Application - Girl Talk Inc

Please select the position(s) you would like to apply for:*

Name*

First Middle Last

Preferred Name*

Date of Birth*

Home Address*

Street Address Address Line 2 City State ZIP Code

Email*

Cell Phone Number*

Home Phone Number

Work Phone Number

Best way to contact you?*

Ethnicity*

If you said Other, what is your ethnicity?

Gender*

Highest Education Level

Marital Status*

Why do you want to be a Girl Talk Mentor?*

Employment Information

Name of Employer*

Occupation*

Work Address*

Street Address Address Line 2 City State ZIP Code

May we contact you at work?*

Yes
No

How long at this employer?*

Background Check Information

Please upload a copy of your valid driver's license.*

Max. file size: 300 MB.

Mentors must provide documentation along with this application validating that you have a valid driver's license and have auto insurance. These credentials allow you to participate in the Girl Talk mentoring program and to transport youth in any vehicle you are operating.

Driver's License Number*

State Issued*

Driver's License Expiration Date*

Do you have a criminal record?*

If so, please explain the details of such record (offense, date, location, circumstance, outcome):

Community Involvement

Organization Name 1

Position Held

Length of Time Involved

May we contact them to recruit mentors?

Organization Name 2

Position Held

Length of Time Involved

May we contact them to recruit mentors?

Organization Name 3

Position Held

Length of Time Involved

May we contact them to recruit mentors?

Community Organization 4

Position Name

Length of Time Involved

May we contact them to recruit mentors?

Community Organization 5

Position Held

Length of Time Involved

May we contact them to recruit mentors?

Have you ever been, or applied to be, a mentor?*

If yes, where and when?

How did you hear about Girl Talk, Inc.?*

Please specify the name of the individual or organization, etc.?

References

Please list four references who have known you for over a year and observed you with children. Do not include more than one family member.

Reference #1*

First Last

Relationship to you*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone #*

Cell Phone #*

Reference #2*

First Last

Relationship to you*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone #*

Cell Phone #*

Reference #3*

First Last

Relationship to you*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone #*

Cell Phone #*

Reference #4*

First Last

Relationship to you*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone #*

Cell Phone #*

Referrals

Please provide us with at least three people you think would also make great mentors.

Referral #1

First Last

Relationship to you

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone #

Cell Phone #

Referral #2

First Last

Relationship to you

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone #

Cell Phone #

Referral #3

First Last

Relationship to you

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone #

Cell Phone #

Statement of Agreement*

I agree.

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 mentor services; 3) The information I provided may be used to conduct a background check, to include driving records check, criminal background and sexual offender register registry checks and other records where required by local, state, or federal law for mentors working with youth; 4) I will provide documentation to transport youth in the vehicle I operate, which includes a valid driver’s license and current automobile insurance; 5) Girl Talk 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.

Confidentiality Policy*

I agree to the confidentiality policy.

Girl Talk Inc. respects the confidentiality of the "Girl Talk Girl" and Girl Talk Mentor records and, with the exception of situations listed below, shares information about Girl Talk Girls and Girl Talk mentors only among the agency professional staff. All records are considered the property of the agency and not the agency workers or Girl Talk Girls or Girl Talk mentors themselves. Records are not available for review by the Girl Talk Girls or mentors.

1. Information will be released to other individuals or non-Girl Talk Inc. organizations only with the Girl Talk Girl's or Girl Talk Mentor’s written consent.

2. Identifying information regarding Girl Talk Girls and Girl Talk Mentors may be used in agency publications or promotional materials unless the clients or volunteer request otherwise.

3. Members of the Board of Directors or evaluators appointed by the Board have access to client files upon authorization of the Board of Directors.

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

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

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

7. If an agency worker receives information indicating that a Girl Talk Girls or Girl Talk Mentor may be dangerous to 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.

8. At the time a Girl Talk Girl or Girl Talk Mentor is considered as a match candidate, information is shared between the prospective match parties. The information about the mentor may include such items such as: age, sex, race, religion, interests, hobbies, marital and family status, sexual orientation, living situation, etc. Information about the Girl Talk Girl 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 Girl Talk Girl, Girl Talk Girl, or the Girl Talk mentor). I also acknowledge that such information should be shared judiciously even within the ranks of Girl Talk Inc., only with persons who have a specific need to know the information, and only in situations where others would not overhear such communication. If I act outside of the scope of my role as a Girl Talk Mentor, and violate this confidentiality policy, I understand that I can be held personally liable.

Consent for Background Check*

I consent to a background check.

1. In connection with my application for volunteer work, I understand that an investigative criminal, sex-offender and motor vehicle report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination for past employment. I understand that as directed by company policy and consistent with the position described, you may be requesting information from public and private sources about my: driving record, credentials, criminal history records and references. 2. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state and county agencies. 3. By my signature below, I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference, or insurance company contacted by Girl Talk, Inc. to furnish the information described in Section 1. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.

Full Legal Name*

Dates known by this name.*

Other Names You Have Used:

Dates Used:

Social Security Number*

Have you ever lived at any other address(es) in the past 5 years, other than the address listed previously in the application?*

Previous address(es) and how long you resided at this address:

Inital here*

Girl Talk Mentor Application

Employment Information

Background Check Information

Community Involvement

References

Referrals