Thank you for downloading your Bev's Kid Reach Mentor Application! 1. Please print this PDF 2.

Complete the application 3. Get the application to our office - Mail: 402 W. Front St. Tyler, TX 75701 - Scan & Email: mark_richardson@pathhelps.org - FAX: 903-592-1827 4. When received, you will be call to schedule your interview.

Bev's Kid Reach - Mentor Application

Mentor Information
Full Name (First, Middle, Last): Maiden Name: Date of Birth (MM-DD-YYYY): Address (Street, City, State, Zip):

Home Phone:

Cell Phone:

Email Address

Education Information
Highest Level of Education Degree (if applicable ):

High School Attended:

University Attended (if applicable ):

Your Strongest School Subjects:

All Information will be Confidential, Securely Stored, and Disposed of Property

Professional Information
Occupation:

Employer:

Phone Number:

Years, Months at Current Employer:

Regular Work Hours:

Driving Record
Driver's License Number: Driver's License State:

Number of Years You have Driven:

Number of Moving Violations in Past 3 Years:

Have You Ever Been Convicted of a DWI or DUI:

Automobile Insurance Company:

Insurance Expiration:

All Information will be Confidential, Securely Stored, and Disposed of Property

LEGAL RECORD
PLEASE LIST ANY ARREST, CONVICTIONS, ALLEGATIONS OF CHILD ABUSE OR NEGLECT AND RECENT TRAFFIC VIOLATIONS. ARREST / VIOLATION DATE CHARGE DISPOSITION / RESULT

OFFICE USE ONLY: BACKGROUND CHECK

PASSED

FAILED PATH Staff

Family Information
Current Relationship Status: Single Dating Engaged Married List All Children Living in your Household - Full Name (First, Middle, Last): Age Widow School / Grade Other

All Information will be Confidential, Securely Stored, and Disposed of Property

References
Every Mentor is asked to provide a total of THREE character references that will be checked. Please notify your references that you have listed them. Please provide ONE professional reference that you have known for at least 1 year . The remaining TWO references should be personal references that you have known for at least 2 years. (please no family members, spouses, or significant others) Name Phone Number E-Mail Relationship

Office Interview
Please list three dates and a 30 minute time slot that would work best for your schedule: We will be contacting you via email to finalize a meeting date/time/location. The interview will be held in the office of the Program Coordinator. Please make your three dates Monday, Tuesday, Wednesday, and Thursday between the hours of 8:00 am and 5:30 pm. Priority Upcoming Date Time

1 2 3
I, _____________________________________________hereby attest that all information is accurate and true and understand that supplying incomplete or inaccurate information may result in my removal from the Bev's Kid Reach Program. I also agree to inform the Bev's Kid Reach Coordinator if any of the information on this document changes during the time that I am involved with Bev's Kid Reach and PATH.

MENTOR SIGNATURE
Information Privacy

DATE

As stated above, please rest assured that all of the content provided on this application will be confidential, securely stored, and disposed of properly when no longer needed. Limited access will be provided on an as needed basis to Bev's Kid Reach and its agents. Should you have any concerns about your information being on file or accessed by other staff members or its agents, please contact the Program Coordinator.

Last Name

Years

FOR OFFICE USE ONLY Relationship

Notes

Confidential Release of Information for Volunteer Screening Background Check

In order for Bev's Kid Reach to complete the process of MENTOR applications, it is our policy to have a routine national / state criminal background check, child abuse / neglect registry check, and a MVR (motor vehicle registration) check for all MENTORS working with children in the program. Results of the background checks and screenings remain confidential and will be handled as such. Reports are considered the property of Bev's Kid Reach Mentoring Pogrom of PATH. Do you have any objections to a background check and the screenings listed above as a condition of being accepted as a Mentor? - No, you have no objections. - Yes, you object

MENTOR SIGNATURE

DATE

Authorization For Reference Check

I, __________________________________, do hereby authorize any listed references to furnish Bev's Kid Reach Mentoring Program of PATH any information they may have concerning me and do hereby release such individuals and Bev's Kid Reach Mentoring Program of PATH from all liability for any damages whatsoever for issuing such information.

MENTOR SIGNATURE

DATE

Transportation Release
I, __________________________________, will not hold persons connected with Bev's Kid Reach Mentoring Program of PATH, or the organization itself, liable for any injury received by me while transporting, being transported, or while engaged in any planned activities of Bev's Kid Reach Mentoring Program of PATH

MENTOR SIGNATURE

DATE

Photo and Press Release

I, __________________________________, do hereby give Bev's Kid Reach Mentoring Program of PATH, their assignees, licenses and legal representatives the irrevocable right to use my name, picture, portrait, photograph, and visual likeness in all forms of media in all manners, including photo, film, audio presentations for nonprofit, public purposes, and I waive any right to inspect or approve the finished product that may be created in connection therewith. I have read this release and I am fully familiar with it's content.

MENTOR SIGNATURE DATE _______ No, Please do not use my photograph for the purpose of publicity or recruitment efforts for Bev's Kid Reach Mentoring Program of PATH.

MATCHING INFORMATION
Circle all activities you enjoy teaching / participating in:
HORSEBACK RIDING CAMPING / HIKING BILLIARDS / POOL CANOEING / BOATING SKATEBOARDING / SKATING PHOTOGHRAPHY GARDENING READING RC BOATS, CARS, AIRPLANES COOKING BOARD GAMES / CARD GAMES SHOPPING PING-PONG WATCHING MOVIES / VIDEOS ARTS & CRAFTS KAYAKING / SUPING COLLECTING VIDEO GAMES THROWING DARTS MUSEUMS TREASURE HUNTING SEWING / CLOTHES DESIGN VIRTUAL ROLE PLAYING GAMES
SOCIAL MEDIA / WEBSITE DESIGN

DISTANCE RUNNING BICYCLING DANCE, BALLET, TAP CROSS-FIT TRAINING BOXING / WRESTLING MARTIAL ARTS AEROBICS / YOGA / ZUMBA LACROSS / FIELD HOCKEY PARKOUR BOWLING GOLF - Regular, Miniature, & Disc SWIMMING

TENNIS FOOTBALL BASKETBALL BASEBALL SOFTBALL SOCCER HOCKEY VOLLEYBALL TRACK & FIELD GYMNASTICS CHEERLEADING DANCE / DRILL TEAM

List any other activities or interest not listed above:

Why do you want to be a mentor?

Do you have any previous experience volunteering or working with youth? If so, please describe?

What qualities, skills, or other attributes do you feel you have that would benefit a youth?

Can you commit to mentoring for a minimum of one year from the time your matched? Are you available to meet a child 4 hours per month (1 hour per week / 2 hours twice a month? Describe your general health.

YES YES NO YES YES NO

NO NO

Do you, or any member of your household, use tobacco products? If so, how often?

YES

NO

Do you drink alcoholic beverage? If so, What do you drink and how often?

YES

NO

Have you ever been treated or hospitalized for a mental disorder or substance abuse? Briefly Explain.

YES

YES NO

NO

Have you ever been investigated by CPS or convicted of child abuse or neglect? Are you willing to communicate regularly and openly with the Bev's Kid Reach Staff about your match? As a child or teenager, did you have a mentor? List any clubs or organizations of which you are presently a member?

YES YES YES

NO NO NO

MENTOR PROFILE
1 HOW WOULD YOU DESCRIBE YOUR COMMUNICATION SKILL? LIFE OF THE PARTY FRIENDLY AND OUTGOING USUALLY WAIT TO BE APPROACHED BY SOMEONE NEW RESERVED UNTIL I GET TO KNOW SOMEONE NEW NONE OF THE ABOVE (please describe_______________________________________) WHAT TYPE OF CHILD WOULD YOU PREFER TO MENTOR? AGGRESSIVE, THE ONE WHO TAKES THE LEAD VERY INVOLVED AND OPEN PARTICIPATORY BUT NOT TOO ASSERTIVE RESERVED AND ON THE QUITE SIDE ANY CHILD IS FINE WITH ME WHY I AM INTERESTED IN BECOMING A MENTOR WITH BEV'S KID REACH (check all that apply) I THINK I WOULD BE A POSITIVE ROLE MODEL I HAVE THE TIME TO GIVE BACK TO THE COMMUNITY I OVERCAME DIFFICULTIES GROWING UP AND WOULD LIKE TO HELP A CHILD I THINK I HAVE THE PERSONALITY AND ABILITIES TO BE A GOOD MENTOR I AM INTERESTED IN A LONG TERM RELATIONSHIP WITH A CHILD I BELIEVE IN THE VALUE OF MENTORING I WISH I HAD A MENTOR WHEN I WAS IN SCHOOL

PLEASE PRIORITIZE THE FOLLOWING CRITERIA YOU WOULD PREFER IN AN MENTEE?

SAME ETHNICITY SIMILAR PERSONAL INTERESTS SIMILAR BACKGROUND OTHER (please specify____________________________________________________) NO PREFERENCE

HOW COMFORTABLE WOULD YOU BE IN SPEAKING WITH YOUR MENTEE REGARDING HIS OR HER POOR JUDGEMENT? VERY COMFORTABLE SOMEWHAT NOT AT ALL HOW COMFORTABLE WOULD YOU BE IN SPEAKING WITH YOUR MENTEE ABOUT DRUG AND ALCOHOL ABUSE? VERY COMFORTABLE SOMEWHAT NOT AT ALL PLEASE PRIORITIZE THOSE ACTIVITIES THAT YOU SEE ARE MOST IMPORTANT IN A MENTOR RELATIONSHIP? (1-5) PARTICIPATE IN SCHOOL ACTIVITIES ASSIST IN SOCIAL SKILLS DEVELOPMENT PROVIDE ENCOURAGEMENT AND SUPPORT BE A FRIEND INTRODUCE THE CHILD TO NEW EXPERIENCES AND OPPORTUNITIES HOW DID YOU LEARN ABOUT BEV'S KID REACH MENTORING PROGRAM? RECRUITED BY A CURRENT MEMBER OR VOLUNTEER FRIEND BUSINESS COLLEGUE RECRUITED BY STAFF OF BUSINESS OR CIVIC GROUP OTHER (please specify____________________________________________________)

MENTOR HOME ASSESSMENT QUESTIONNAIRE

1 IF YOU WERE TO BRING YOUR MENTEE TO YOUR HOME TODAY, IS THERE ANYTHING YOU WOULD WANT TO CHANGE O MAKE IT MORE SUITABLE FOR THE CHILD?

DO YOU EXPECT TO MAKE ANY CHANGES TO YOUR HOME ENVIROMENT IN THE NEXT YEAR? (moving, additions)

DO YOU HAVE SMOKE DETECTORS AND CARBON-MONOXIDE DETECTORS IN YOUR HOME?

DO YOU KEEP ALCOHOL IN YOUR HOME, AND IF SO WHERE IS IT STORED?

DO YOU HAVE ANY WEAPONS IN YOUR HOME? IF SO, WHERE DO YOU STORE THEM AND THE AMMUNITION?

DO YOU HAFVE ACCESS TO TV / CABLE STATIONS THAT ARE INAPPROPRITATE FOR CHILDREN? IF SO, HOW DO YOU PLAN ON PREVENTING YOUR MENTEE FROM ACCIDENTLY FINDING THEM?

DO YOU HAVE PASSWORD PROTECTION ON ALL ELECTRONIC DEVICES IN YOUR HOME THAT HAVE ACCESS TO THE INTERNET?

WHAT IS YOUR NEIGHBORHOOD LIKE?

HOW WOULD YOU DESCRIBE WHERE YOU LIVE? SINGLE HOME MULTI-FAMILY HOME CONDOMINIUM APARTMENT DORMATORY HOW FAR FROM YOUR HOME DOES THE CLOSEST REGISTARED SEX OFFENDER RESIDE?

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THE 25 STEP MATCHING PROCESS

1. Mentor obtains applicaton. (Picked up at PATH, Mailed to Mentor, or Emailed PDF) 2. Mentor completes applicaton. 3. Mentor calls BKR Coordinator and schedules interview. 4. Mentor give application to front desk. 5. BKR Coordinator reviews Mentor's application. 6. BKR Coordinator interviews Mentor. 7. BKR Coordinator and Mentor schedule New Mentor Training. (pending approval) 8. BKR Coordinator contacts and interviews all three references. 9. PATH (People Attempting To Help) conducts extensive background check. 10. BKR Coordinator will email approval or denial of application to be a mentor. 11. Mentor attends New Mentor Training conducted by BKR Coordinator or Staff. 12. Mentee Applications/Interviews reviewed to find best match for Mentor. 13. Mentor is contacted and given the Mentee's generic description. 14. If Mentor thinks match would would, Mentee's Parent / Guardian is contacted. 15. Mentee's Parent / Guardian contacted and given Mentor's generic description. 16. If Mentee's Parent / Guardian thinks the match is good, Mentor is contacted. 17. Mentor contacted and given specific details of Mentee and their contact information. 18. Mentor contacts Mentee's Parent / Guardian and schedule a time to meet with the BKR Coordinator. (M-Th 8am - 5 pm) 19. Mentor contacts BKR Coordinator and schedule the offical matching. 20. Mentor, Mentee, Mentee's Parent / Guardian meet with BKR Coordinator and review and sign Ground Rules. 21. Mentro, Mentee, Mentee's Parent / Guardian sign Match Agreement. 22. Mentor and Mentee left in room and discuss and schedule their first outing. 23. Mentor and Mentee rejoin Mentee's Parent / Guardian and BKR Coordinator and tell results and take pictures. 24. Mentor and Mentee are reminded of our first report date and reminded of the their annual evaluation date. 25. BKR Coorindator post pictures and generic match information on Facebook.

Terms: BKR. Bev's Kid Reach Mentoring Program BKR Coordinator Bev's Kid Reach Program Coordinator Mentor. Both Approved and Prospective Mentors MenteeBoth Approved and Prospective Mentees Parent / Guardian. The adult (s) that are legally responsible for the Mentee

Bev's Kid Reach Ground Rules

1. The Mentor does not become involved in the discipline of the Mentee. The Mentor is a friend, not a Parent. 2. The parent does not deprive the Mentee of weekly contact with the volunteer as a means of discipline. 3. The Mentor does not spend time in the Mentees home; this will avoid involvement with other family members. The Mentor must check in with guardian at the beginning and end of each visit. 4. The Mentor does not include the Mentees siblings or other family members in match activities; except in the event that a Mentoring family (ex. Husband and Wife) each are matched with two Mentees that are from the same family (ex. Brother and Sister). The Mentor does not involve their family members in match activities as well. 5. The parent does not request favors of the Mentor. 6. The Mentor does not assume legal responsibility for the Mentee. If a problem arises, the Mentor will not intercede for the parent. 7. The Mentor will not assume financial responsibility for the child or family. Mentors will be responsible for expenses incurred during outings. Gifting is not advised. 8. The parent does not involve the Mentor in family problems where the Mentor would be used as a disciplinarian or go between with the parent / child relationship. 9. The Mentor and parent will communicate about match activities so as to avoid schedule conflicts or misunderstandings. Good communication between all parties is the key to a successful misunderstandings. Good communication between all parties is the key to a successful 10. No overnight visits allowed between match mates in the first six months of the match. Overnight visits after the initial six-month match period must be approved by the Bevs Kid Reach Program Coordinator and written parental support for such a visit must be confirmed one week prior to match activity 11. No trips within the initial six-month match period will be taken that will exceed a one-hour driving distance from the mentees home unless the Bevs Kid Reach Coordinator gives permission and written parental support is received in the office one week prior to the match activity. 12. Foul language, the consumption of drugs, alcohol or other such inappropriate behaviors are prohibited prior to and during a match activity. 13. Mentee must wear a safety belt when in a vehicle. 14. Mentor will keep all firearms out of reach and secure from Mentee at all times. 15. All precautions must be exhibited when match activities include water sports. 16. Parent and Mentor should discuss ratings of movies/videos and video games. 17. The Mentor and Family must follow the supervision schedule as explained by coordinator. Failure to follow the schedule, (one hour a week or two hours twice a month is preferable, but at least four hours a month is required), without contacting Bevs Kid Reach staff could result in match closure. We simply ask for good communication and care from all parties. 18. The Mentor understands and agrees that at all times during the match outings, the child is their sole responsibility. The Mentor will not leave the child alone with, or in the care of, another person. The Mentor will not knowingly bring Mentee around anyone convicted of any form of child abuse. 19. All Mentor / Mentee matches will be same sex matches. 20. The Mentor will notify Bevs Kid Reach Coordinator immediately if any arrest or of any charges filed against the Mentor while he or she is a Mentor. I have read over and understand the basic ground rules for the Bev's Kid Reach Mentor Program at PATH and I have received a copy of these rules. I further understand that failure to comply with these rules can result in the closure of my match and removal from the program.

Name_____________________________________________________

Date________________

PATH / Bev's Kid Reach Criminal Background Policies

Policy for Criminal Background Screenings:
All new or potential mentors must complete an application packet which includes a Background Verification Release Form. In order to conclude the background check mentors must include their driver's license number. Once the criminal background check has been finished PATH staff will evaluate the information and a decision will be made.

Background Check Offenses:

As a general rule, subject to the specific nature and severity of the offense (s), the mentor applicant may be deemed ineligible to work or provide services to PATH / Bev's Kid Reach if the mentor is identified as having committed any of the following offense (s): > Any offense against a minor within the past 10 years. > A sexual offense within the past 10 years. > Any matter involving a felony within the past 10 years. > Any drug offense within the past 5 years. > Any alcohol offense within the past 3 years. > Any other offense that is deemed relevant to the subject's assignment within the past 5 years > Any re-occurring matter involving any other type of criminal offense, especially if more than one occurrence of the same type of offense is alleged to have taken place within the previous 8 years. Although a disqualification is possible, a previous conviction does not automatically disqualify an applicant from consideration of mentoring with PATH / Bev's Kid Reach. The Executive Director, Program Director, and the Program Coordinator will together consider the following factors in determining whether a candidate is eligible for mentoring with PATH / Bev's Kid Reach. > > > > > The relevance of the conviction to the duties and responsibilities of the position for which selected The nature of the conviction (s) The age of the candidate when the illegal activity occurred The dates of the convictions The candidate/s record since the date (s) of the conviction (s)

Disqualification from Mentor Participation

The following rules apply if PATH / Bev's Kid Reach learns (via criminal background search) that a prospective mentor has been convicted of, has pled guilty to, has deferred adjudicative for, or has pled no contest to one of the following crimes under the laws o f the State within the United States, or any other nation. > Homicide > Crimes of rape, criminal sexual penetration, criminal sexual contact, incest, indecent exposure, or other related sexual offenses. > Crimes using a weapon > Arson > Any violent crime, felony drug-related offense or trafficking in controlled substances > Crimes involving child abuse, neglect, or residing on the same premises as a registered sex offender > Crimes involving adult abuse, neglect or financial exploitation Any Information supplied by potential mentor is held in strictest confidence and not divulged to any other staff member, board member, or volunteer of PATH / Bev's Kid Reach.