New Circle Mentor Application

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Basic Information:

Contact information:

Demographics:

Home Address:

Previous Residences:

Please list the last three previous residences you have lived in.

Employment:

Previous Employment:

Please list your last 2 previous employers.
Previous Employer 1
Previous Employer 2
Previous Employer 1
Previous Employer 2
Previous Employer 1
Previous Employer 2

References:

Please list 3 references whom the agency may contact in support of your application to become a mentor. Please have one professional reference who has known you for at least six months unless there are extenuating circumstances. Provide two personal references who have known you for at least two years.
Professional Reference
Personal Reference
Personal Reference
Professional Reference
Personal Reference
Personal Reference
Professional Reference
Personal Reference
Personal Reference
Professional Reference
Personal Reference
Personal Reference

Application Information:

Up to "x" miles.

Skills and interests:

Certifications:

New Circle Mentoring requires a three-year mentor relationship commitment.
New Circle Mentoring requires a commitment of 4 hours per month.

Additional Information:

Application Information Release:

I understand that I have made an application for a volunteer opportunity with Safer Society Foundation, Inc.(SSF), and it is not a commitment or promise of a volunteer opportunity by SSF. I understand that it is in SSF discretion whether to accept me as a mentor and SSF has no obligation to provide me with a reason for its decision to accept or reject me as a mentor. I represent and warrant to the SSF that all information that I have or will provide to SSF during the selection process, including information on this application and in interviews with SSF, is true, correct and complete to the best of my knowledge. I further agree that I have and will answer all questions posed by SSF to the best of my knowledge and that I have not and will not withhold any information that would unfavorably affect my application for a volunteer position. I understand that any misrepresentations or omissions by me may be cause for my immediate rejection as an applicant for a volunteer position with SSF or my termination as a volunteer. I hereby authorize SSF to request and obtain any and all records, documents and information about me from employers, SSF and references included on my application necessary for SSF to evaluate my suitability as a mentor. I understand that SSF will check some or all of the following: my records on the national sex offender registry, the Vermont child abuse and neglect registry, national criminal records background check, the Vermont criminal conviction search, and Vermont Motor Vehicles Driver Record Check. I hereby consent to the release of such records, documents, and information to SSF and to the SSF designated representatives. I release and agree to defend and hold harmless from liability any person or organization that provides information. I agree and acknowledge that this information may be disclosed by SSF officials to persons involved in the implementation of SSF activities and programs. I hereby release and agree to defend and indemnify the SSF, its directors, officers, partners, employees, affiliates, agents, successors, and its designated representative from any and all claims that may result from the use, release and disclosure of such information. I HAVE CAREFULLY REVIEWED THIS "INFORMATION RELEASE AND COVENANT NOT TO SUE" AND I HEREBY CONFIRM MY UNDERSTANDING OF ITS CONTENTS AND AGREE TO BE BOUND BY ITS TERMS AS A CONDITION OF MY PARTICIPATION IN THE ABOVE ACTIVITY.
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