1. Identifying Information
First Name (required)
Middle Name (required)
Last Name (required)
Date of Birth (required)
Home Address (required)
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Zip Code (required)
Home Phone (required)
Email Address (required)
Place of Employment (required)
Business Phone (required)
Driver's License # (first four digits only) (required)
Current Job Title (required)
Employment Length (required)
2. Background Information
1. Ethnic Group (Please select one)(required)
African American American Indian Asian Caucasian Hispanic Other
If Other, please specify
2. Age Category (required)
18-30 31-40 41-50 51-60 60+
3. Are you married? (required)
4. Do you have children? (required)
5. Answer 'yes' to the following question if you have ever been charged, convicted, had adjudication withheld or entered a pretrial intervention program for a criminal charge, either misdemeanor or felony. (required)
If 'yes', please submit a brief statement regarding the circumstance(s). Note that answering 'yes' does not immediately preclude you from volunteering within the county, but failure to answer accurately and completely will delay the processing.
3. Mentor Information
4. How would you describe your communication style? (required)
Friendly and outgoing. Usually wait to be approached by someone new. Reserved until I get to know someone new. None of the above.
If 'None of the above', describe
5.I am interested in becoming a mentor because: (check all types that apply)
I think I'd be a positive role model I like children I have the time to give I overcame difficulties growing up and would like to help someone else I think I have the personality and abilities to be a good mentor I am interested in making a difference in the life of a child I believe in the value of mentoring I wish I had had a mentor when I was a teenager
List any clubs or organizations of which you are currently a member.
6. From the following descriptions, which type of child would you like to mentor? (check all types that apply)
Type 1: A or A/B student - no school, attendance or behavioral problems Type 2: B/C student - may have some school related problems, home instability Type 3: C student - may be struggling in academics, may have a lack of motivation for school, may have some discipline problems, and may have home instability. Success for this student may be to graduate from high school Type 4: In addition to any of the above, may have a physical or learning disability
7. How did you learn about the Take Stock in Children program?
From a current Take Stock memberFrom business or civic groupFriendBusiness colleagueOther
8. Which schools are you willing to serve? (Check all that apply)
Anclote High Chasco Middle Cypress Creek Middle/High Fivay High Gulf High Hudson High Hudson Middle Land O Lakes High Mitchell High Pace Center Pasco High Pine View Middle R.B. Stewart Middle Ridgewood High River Ridge High Sunlake High Wesley Chapel High Wiregrass High Zephyrhills High
Please complete the following information listing two (2) references. Do not include spouses, family members, and boy/girl friends.
Years known (required)
Phone Number (required)
Relationship (personal friend, work reference) (required)
Provide Second Reference
As a mentor in the Take Stock in Children program, I will act in a behavior that is in the best interest of my student. Accordingly, I pledge to each of the following volunteer policy statements: (Please check indicating your approval)
A. I will notify the Take Stock in Children Pasco Office of any situations or conversations that may be uncomfortable to me or that may require additional intervention.
B. I will notify my student, his/her school liaison or the Take Stock in Children Pasco Office if I am unable to attend a previously scheduled meeting.
C. I will notify the Take Stock in Children Pasco Office if I must terminate my mentor position for any reason.
D. I will communicate with the Take Stock in Children Pasco Office about my monthly Mentor Sessions by registering each session electronically, and will commit to adhering to the 15 meetings per school year requirement.
E. I will not arrange face-to-face contact with my student off school property if not under the supervision of Take Stock in Children or the Pasco County School District.
F. I will not drive my student in my car without receiving prior approval from the Take Stock in Children Pasco Office.
G. I understand all information pertaining to students and their families is confidential and must not be revealed to any person or agency without specific written permission from the Take Stock in Children Pasco Office.
I understand, acknowledge and agree with the following statements: (Please check indicating your approval)
A. I will adhere to all volunteer policies of my local school district.
B. The District School Board of Pasco County has established a policy that prohibits bullying and harassment to ensure that all students, employees and volunteers learn and work in an environment that is safe and secure.
C. Bullying is defined as systematically and chronically inflicting physical hurt or psychological distress on one or more students, employees, or volunteers.
D. Bullying may involve but is not limited to teasing; social exclusion; threat; intimidation; stalking (including cyberstalking); physical violence; theft; sexual, religious or racial harassment; public humiliation; and destruction of property.
E. It is understood that I am offering my services to the Pasco Education Foundation, Inc. without compensation.
F. I hereby give my permission for the District School Board of Pasco County to perform a background check so that I may become eligible to become a mentor and give the Pasco Education Foundation, Inc. permission to release my name to Take Stock in Children. All volunteers must be pre-approved.
G. I acknowledge and agree that I am not obligated if called upon to perform the volunteer services herein applied for and Take Stock is not obligated to assign me a Take Stock student.
H. I acknowledge and agree that as a part of the Take Stock matching process, additional information may be elicited from the applicant by the Take Stock in Children Pasco office.
I. I acknowledge and agree that Take Stock in Children Pasco Office reserves the right at all times to terminate any match between any volunteer and student, for whatever cause.
J. I give permission to photograph which includes portraits, pictures, or videotapes, which may, in whole or part, be used in conjunction with the Take Stock in Children Program.
K. I waive any right to inspect and approve the photograph, pictures, videotape, biographical sketch, or the use for which they may be applied. This release is valid the entire time I remain a Take Stock in Children mentor.
L. All volunteers must sign in and out through the RAPTOR system. Raptor will record the volunteer’s name, date and hours of service (on or off campus), and tasks assigned. RAPTOR can generate reports for school and District accountability.
M. I declare that all of the statements made in this application are true, complete and correct to the best of my knowledge.
Applicant Electronic Signature (required)
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