STARS Mentoring Program

STARS Mentoring Program

MENTOR APPLICATION

Date

PartI. Identification Information

Last Name First Name Middle Initial

Home Address CityState Zip

How long have you lived in this community?

If less than 5 years, where have you lived previously?

Home Phone Number Cell Phone Number

E-mail Address:

Driver’s License Car License

Car Insurance Company Policy Number

Where did you learn about STARS?

Why do you want to be a mentor?

What do you hope to gain from a mentoring experience?

Part II. Employment Information

Circle current working status:Full TimePart TimeRetired

If retired, list most recent position and omit the contact information.

Current PositionCompany

AddressCityStateZip

Work Phone NumberFAX

E-mail AddressPager

May we contact you at work?Yes NoApproximate Hours (i.e. 8am-5pm)

How long have you been at your current position?

What other working experiences have you had?

Part III. Availability and Applicable Experience

When are you available to mentor? (Circle all that apply)

Mondays TuesdaysWednesdayThursday Fridays SaturdaysSundays

Approximately how many hours per week can you mentor? (Circle)

1 to 5 hours5 to 10 hours 10 to 15 hours 15 to 20 hours More than 20 hours

Do you speak a second language?Yes NoSpecify

Have you traveled to another country? YesNoSpecify

What experiences have you had in working with children/youth?

Do you have any impairment that might affect your ability to mentor? If so, please list.

Are you taking any medications that could affect your ability to mentor? If so, please list.

If accepted as a mentor, may we use your photo/name to promote STARS? Yes No

The safety of the youth in our program is foremost in importance. Therefore, please answer the following questions by circling yes or no and providing any appropriate details:

1. Have you used illegal drugs?YesNo If so, when?

1. Have you ever been convicted of a criminal offense? YesNo

If so, list offense(s) and date of conviction:

1. Are there any criminal charges pending against you?Yes No

1. Do you currently have a valid driver’s license?Yes No

1. Are there any restrictions upon its use? Yes No

If so, list.

6. Has your driver’s license ever been revoked? Yes No If so, explain.

7. Is there any other circumstance that would call into Yes No

question your being entrusted to supervise, guide,

transport or care for a youth? If so, explain.

Part IV. Verification of Accuracy

I certify that the information provided on this application is true and accurate, to the best of

my ability, and may be verified by contacting my references. I hereby release from liability any person or organization that provides information to STARS. I understand that knowingly providing misinformation here, and on subsequent forms as part of the process for becoming a mentor, is grounds for dismissal.

Signature RequiredDate

V. REFERENCES – REQUIRED

Please list the following information for three people who will vouch for your character. Include at least one person you have worked for or with. Do not list family members. PLEASE PROVIDE MAILING ADDRESS.

Name

Relationship to you

Address

CityStateZip

Daytime Phone Number

*********************

Name

Relationship to you

Address

CityStateZip

Daytime Phone Number

*********************

Name

Relationship to you

Address

CityStateZip

Daytime Phone Number

Note that it takes a few weeks to process your application, complete the background check, and contact your references. You will be notified of the results as soon as possible. We regret that we cannot provide reasons for non-acceptance because we must guarantee that responses from references remain confidential.

STARS

Success Through Adults Reaching Students

2202 Stevens Street, Albert Lea, MN 56007

T078743376 – Nonprofit Organization

Phone: 507-383-5272

Child Protection Background Check

Because the position for which you are applying will require you to provide care, treatment, education, training, instruction, or recreation to children, STARS Mentor Program will request the Bureau of Criminal Apprehension (BCA) to perform a criminal background check on you under Minnesota Statutes Chapter 299C.62.

Have you ever been convicted of any of the following crimes? (If yes, please

attach a description of the crime and the particulars of the conviction.) Yes No

BACKGROUND CHECK CRIMES

Under Minnesota Statutes Chapter 299C

– Murder– Felony Level Assault– Kidnapping

– Criminal Sexual Conduct– Manslaughter– Arson

– Any Assault Crime Against a Minor– Prostitution-Related Crime

– Any of the following Child Abuse Crimes committed against Minor Victim, constituting a violation of Minnesota Statues Sections:

609.185,(5) Murder in the 1st Degree / 609.344 Criminal Sexual Conduct in the 3rd Degree
609.221 Assault in the 1st Degree / 609.345 Criminal Sexual conduct in the 4th Degree
609.222 Assault in the 2nd Degree / 609.352 Solicitation of Children to Engage in Sexual Conduct
609.223 Assault in the 3rd Degree / 609.377 Malicious Punishment of a Child
609.224 Assault in the 5th Degree / 609.378 Neglect or Endangerment of a Child
609.2242 Domestic Assault / 152.021, subd. 1,(4) Controlled Substance Crime in 1st Degree
609.322 Solicitation, Inducement & Promotion of Prostitution / 152.022, subd. 1,(5) or (6) Controlled Substance Crime in 2nd Degree
609.324 Other prohibited acts of Prostitution / 152.023, subd. 1,(3) or (4) Controlled Substance Crime in 3rd Degree
609.342 Criminal Sexual Conduct in the 1st Degree / 152.023, subd. 2,(4) or (6) Controlled Substance Crime in 3rd Degree
609.343 Criminal Sexual Conduct in the 2nd Degree / 152.024, subd. 1,(2),(3) or (4) Controlled Substance Crime in 4th Degree

As the subject of a Child Protection background check, your rights include:

• to be informed that STARS Mentor Program will request this check for becoming or continuing as an employee or volunteer, and to determine whether you have been convicted of any of the above specified crimes, and
• to be informed of the BCA’s response and obtain a copy of the report from STARS Mentor Program,
• to obtain from the BCA any record that forms the basis for the report, and
• to challenge the accuracy and completeness of any information contained in the report, and
• to be informed whether STARS Mentor Program has denied your application because of the BCA’s response and not to be required directly or indirectly to pay the cost of the background check.

Minnesota statues and the BCA require you to complete the following in order to complete the background check:

PLEASE PRINT

Last Name of Applicant:

First Name:

Middle (full):

Maiden, Alias or Former Names:

Date of Birth: Sex: M or F (Circle)

(Month / Day / Year)

Social Security Number (optional):

Signature: Date:

(This release is valid for one year from the date of my signature.)

Background Check Informed Consent

The following named individual has made application to volunteer as a mentor with the STARS Mentoring Program:

Last Name of Applicant:

First Name:

Middle (full):

Maiden, Alias or Former Names:

Date of Birth: Sex: M or F (Circle one)

(Month / Day / Year)

Social Security Number (optional):

I hereby authorize the Minnesota Bureau of Criminal Apprehension and FBI to disclose all criminal history record information to the STARS Mentoring Program, for the purpose of volunteering as a mentor with this agency.

Signature of Applicant Date