Mentor Registration Form

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Personal Information

Applicant's Name

First Last

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Emergency Contact

First Last

Relationship

Phone

Highest Education Level

Ethnicity

Marital Status

How did you hear about us?

Program Information

Please list interests / hobbies (for matching youth)

Desired age/grade levels (please indicate any/all preferences)

Juvenile Justice

Age

Grade Level

School

Age

Grade Level

Community

Age

Grade Level

Available Hours

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Consent

I, the undersigned, including my heirs, executors, administrators and estate, do hereby release and agree to hold Must Care, its board members, officers, directors, employees, volunteers or donors, free from any and all actions, causes of action, claims, demands, costs or damages as a result of property damage or personal injuries or death sustained by myself, my family, or my property, arising from or resulting from any act or omission, negligent or otherwise, while participating in the said activity or while traveling to or from the place at which such activity will be conducted. In the event a volunteer provides transportation for me, or my family, this waiver and release shall extend to and release the volunteer driver or employee driver from any liability aforesaid

I agree.

I, the undersigned, understand it will be necessary for Must Care to conduct a background check regarding my driving record, criminal history, personal references, and employment. I authorize Must Care to obtain any needed information regarding my driving record (if applicable), legal/criminal history, and personal references for the purposes of participating in a mentoring program. Further, I provide permission for Must Care to conduct the same investigation of my background in previous states in which I have resided.

I agree.

Further, I understand that information about me will be anonymously (without my name) shared with a prospective mentee(s) and his/her parent(s)/guardian(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and any other information known about me may be shared with the mentee and parent/guardian to ensure and aid in facilitating a safe and successful match relationship.

I agree.

I understand that based on my interests, I may be matched with a youth who is either one of Must Care’s mentees or with a youth who is a mentee working within one of Must Care’s partner programs.

I agree.

Photographic Release (optional): I grant and convey unto Must Care all right, title and interest in any and all photographic images and video or audio recordings made by Must Care during the Volunteer’s activities with Must Care, including, but not limited to, any royalties, proceeds or other benefits derived from such photographs or recordings.

I agree.