Family & Youth Initiatives Application

CONFIDENTIAL

This application is confidential and needs to be fully completed by the applicant.

I am applying for:

_____ Volunteer Mentor_____Paid Mentor

_____Nurturing Parenting Program facilitator_____Nurturing Parenting Program volunteer

_____Youth in Action Program facilitator_____Youth in Action High School facilitator

_____FYI volunteer

Further application materials may be requested for paid positions

Today’s Date______

Personal Profile

First Name: ______Middle Name: ______Last Name: ______

Physical Address: ______Home phone: ______

Email: ______Cellphone:______

Previous Physical Address (if lived at present address less than 1 year): ______

Social Security #: ______Birthdate: ______Age: ______

If not a United Citizen: Visa Number______Expiration Date:______

Emergency Contact information: Name______Phone # ______

How did you hear about Family & Youth Initiatives?

Briefly describe any other community groups/volunteerism you are involved with:

Education History

List schools attended starting with high school, if you need additional information, please write on the back.

Name of school, address, phone / Graduated, year, degree / Study emphasis
1. / Yes/No
2. / Yes/No
3. / Yes/No

Employment History

Present Employer: ______Phone #: ______

Physical Address: ______Mailing Address: ______

Position:______Supervisor Name: ______

Hours generally worked: ______

May we contact your current employer as a reference? ______

Employer / Position / Length of Employment
1.
2.
3.

Do you have your own transportation? YES NO

Briefly describe your driving history: ______

Traffic violations? YESNO

Please explain.

Have you ever been arrested or convicted of an alcohol-related offense? YES NO

Please explain.

What is your current use of alcohol/marijuana/drugs?

Any current or past problems alcohol/marijuana/drugs?

Treatment/counseling?YESNO

Have you ever been convicted or charged of any crimeYESNO

(ie. Misdemeanor, felony, assaults)Please explain.

Have you ever been arrested or questioned about child abuse or molestation?YES NO

Please explain.

References

List three (3) character references: At least one person who knows your role with youth/young adults/families and one from an employer. Please give each reference a copy of the attached reference form and have them mail it to Family & Youth Initiatives. We will not begin the application process until all reference letters have been received. Thank you.

Name / Relationship / Phone and E-mail / Mailing Address
1.
2.
3.

Tell us about you:

How many times have you moved in the past 5 years?

How long have you lived in Chaffee County?

There is a commitment of one year with the Family & Youth Initiativesprograming; do you see any barriers to fulfill this commitment?Where do you see yourself in 3-5 years? Are you planning on staying in Chaffee County for the next year?

Briefly describe why you would like to be a part of the Family & Youth Initiatives team:

What do you consider your strengths to be?

What do you consider your challenges to be?

Please give an example of a time when you were let down. How did you respond?

What do you know about working with youth and families?

Tell us about your experience in working with adolescents or young adults with disabilities.

What would be the most important message you would want to relate to youth and families?

Do you feel that your age and physical capabilities can meet that of programing? Explain.

Can you abide by the programs and schedule of class sessions, meetings and/or trainings?

If accepted, are you willing to fill out our designated questionnaires that allow us to look at your personality and resiliency factors more closely for compatibility of programing? YES NO

Anything else we should know about you that would help us match you with programing?

Background Check Release

I do hereby authorize Family & Youth Initiativesto conduct whatever background checks and investigation as deemed appropriate for the position for which I am applying (police check, child abuse registry check, mental health, driving record, insurance carrier, personal references, etc.).

Signature: ______Date: ______

Photo Release

I agree to allow any photographs / videos taken of me in connection with FYI program activities to be used in newspapers, displays, bulletin boards, or other types of educational or promotional publication or training.

Signature: ______Date: ______

Survey Release

I agree to completeFamily & Youth Initiatives surveys as required for program compliance and reporting.

Signature: ______Date: ______

Statement of Understanding: Confidentiality and Family & Youth Initiatives /Coach Termination

I have full understanding that client and record confidentiality is essential as a part of the Family & Youth Initiatives team. I feel that I have thorough and satisfactory understanding of professional standards of client and record confidentiality and legal implications thereof. I further agree to respect the dignity of the client and integrity of the Family & Youth InitiativesProgram by maintaining confidentiality of information received in the course of the service.

I fully accept and understand that Family & Youth Initiatives reserves the right to reject any application for any reason at any time without explanations. I also understand that the staff reserves the right to terminate a partnership if they feel the need to.

Signature: ______Date: ______

Accuracy

I verify that the statements I have made on this application are true and complete. I understand that if I am hired, any false or incomplete statements on this application will be grounds for immediate discharge. ( ) initials

Signature: ______Date: ______

Thank you for your time in completing this application

Please return to:

Family & Youth Initiatives

PO Box 1007

448 E 1st Street, Salida, CO 81201

Email: Fax: 539-3537

Contact us at Family & Youth Initiatives: 719-530-2582

After we receive your application and all necessary information collected, you will be contacted to set up a personal interview. We look forward to working with you.

448 East 1st St, P.O. Box 1007, Salida, CO 81201

Salida: (719) 530-2582 / BV: (719) 395-3044 (X204)

Salida fax: (719)539-3537