Boys & Girls Club of Albany Mentor Application
(Please type or print)
Date_____________________
Name of Applicant________________________ Date of Birth___________ SS#____________________
Address____________________________________________________________________________
City____________________________ State___________________ ZIP_________________________
Home phone_____________________________ Home e-mail_________________________________
Employer___________________________________ Occupation_______________________________
Work Address_______________________________________________________________________
City____________________________ State___________________ ZIP_________________________
Business phone____________________ Fax________________ Business e-mail__________________
Preferred Mentoring Day (Mon - Sat) Choice #1__________________ Choice #2___________________
Best Time of Day to mentor (check all that apply): Morning ______ Afternoon_______ Evening_______
Do you prefer to be matched with: (check one): Male_______ Female _______ No preference _____
Do you prefer to be matched with: (check one): Younger youth _____ Teen ______ No preference ____
On the back of this application or a separate sheet of paper, write a brief statement on why you wish to be a mentor in the Mentoring Program at the Boys & Girls Club.
On the back of this application or a separate sheet of paper, describe special interests or hob may be helpful in matching you with a mentee (e.g. cooking, crafts, career interests, games, sports, computers, art, needlepoint, languages, music, painting, etc.).
List the addresses where you have lived for the last five years (begin with the most recent after the current address listed above). Use back of page or separate sheet if more space is needed:
Dates: from______________ to_________________
Address_____________________________________________________________________________
City____________________________ State___________________ ZIP_________________________
Dates: from______________ to_________________
Address____________________________________________________________________________
City____________________________ State___________________ ZIP_________________________
Please provide three personal references (other than family members):
1. Name______________________ Telephone______________ Relationship________________
Address____________________ City___________________ State ______ ZIP_____________
2. Name______________________ Telephone______________ Relationship________________
Address____________________ City___________________ State ______ ZIP_____________
3. Name______________________ Telephone______________ Relationship________________
Address____________________ City___________________ State ______ ZIP_____________
Employment History List the last three places of employment with the most recent first:
1. Company______________________ Occupation _________________Title _________________
Dates from________________ to ________________________
2. Company______________________ Occupation _________________ Title _________________
Dates from________________ to ________________________
3. Company______________________ Occupation _________________ Title _________________
Dates from________________ to ________________________
Mentor Release Statement
I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of the Mentoring Program at the Boys & Girls Club (hereafter known as the "Club"). I understand that the program involves spending a minimum of one hour per week at the Club. I am not allowed to take the youth off the Club grounds. Further, I understand that I will attend a training session, keep in regular contact with my mentee and communicate with staff regularly during this period. I am willing to commit to one year in the program and then may be asked to renew for another year.
I have not been convicted, within the past ten years, of any felony or misdemeanor classified as an offense against a person or family, of public indecency, or a violation involving a state of federally controlled substance. I am not under current indictment. Further, I hereby fully release, discharge and hold harmless the Club, participating organizations and all of their employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs and expenses which may be or may at any time hereafter become attributable to my participation in the Mentoring Program.   I understand that the Club staff reserves the right to terminate a mentor from the program. The program takes place only at the Club and does not encourage or approve of relationships established between mentor/mentee and family members beyond the organized and supervised activities of the program. I give permission for program staff to conduct a criminal background check as part of the screening for entrance into the program. This includes verification of personal and employment references as well as a criminal background check with the authorities. Program staff has final right of acceptance of application into the program and reserves the right to terminate a mentor from the program at any time. I have read this Release Statement and agree to the contents. I certify that all statements in this application are true and accurate.
________________________________________	___________________
(Mentor Signature)	(Date)