Mentor Application

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Name *
Name
To help us match you with a youth we would like to know your interests. Which of these activities do you enjoy? *
For example, someone who is shy, someone who has trouble managing their anger, someone who loves to draw, someone who loves sports, has a learning disability, or of a certain ethnicity?
Someone with emotional issues or any physical or learning disabilities,
Suggestions for activities? Discounts in the community? Training on how to handle difficult situations? Community resources? Case management? Other?
Please list the name, address and phone number of 4 people you would like to list as references.
I hereby authorize the Youth Violence Prevention Council to obtain information pertaining to any charges and/or convictions I may have had for violation of municipal, county, state, or federal laws. This information will include, but is not limited to, allegations regarding and convictions for crimes committed upon minors and will be gathered from any law enforcement agency of this state or any state or federal government or court records. I understand that I will be given an opportunity to challenge the accuracy of any information received that appears to implicate me in criminal activities. To facilitate this challenge, I will be told the nature of the information and the agency from which it was obtained. It will be my responsibility to contact that agency. I further understand that until the Youth Violence Prevention Council receives notification from that agency clearing me, my application will be deferred. I understand that Youth Violence Prevention Council will check my Department of Motor Vehicle records. I hereby attest to the truthfulness of the representations I have made. Except as I have disclosed on the application, I have not been found guilty of, or entered a plea of nolo contendre or guilty to any offense. Further, other than for the offenses I have disclosed, I have not had a finding of delinquency under the juvenile laws of this state or any other state. I further attest that I have not been judicially determined to have committed abuse or neglect of a child; nor do I have a confirmed report of child abuse or neglect or exploitation which has been uncontested or upheld administratively under the laws of this or any other state. I understand that the Youth Violence Prevention Council has the legal right to accept, reject, or terminate candidates at its discretion.