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)
Are you a Take Stock in Children Graduate? (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)
# Sons Age(s)_______ # Daughters_______ Age(s)______
Second Language(s) spoken:
When you were a teenager, to which income group did your family belong?
Low Income Middle Income High Income
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. Career/Education Information
Highest education completed (Check all that apply):
GED High School Graduate Associate’s Degree in Technical/Vocational Certificate Bachelor’s Degree Master’s Degree Doctorate Other
If Other, please specify:
If applicable, where is your degree from and what is it in?
Are you currently enrolled in any education or training program?
If yes, please specify:
4. 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
Do you have any specific training or experience in dealing with any of the following youth issues: (check all that apply.)
Drug Awareness Teen Pregnancy Teen Violence Sex/Abstinence Other
If yes, please explain:
List any clubs or organizations of which you are currently a member.
Which of the following activities do you enjoy participating in or watching? (Check all that apply.)
Sports Handicrafts Outdoor life Mechanics/Science Literature Pop Culture (Movies, TV, Etc.) Collecting Other
Is there anything else you would like us to know about you? If yes, please explain:
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
Are there any particular problems you would prefer not to handle as a mentor?
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 River Ridge High Sunlake High Wesley Chapel High Wendell Krinn Technical High Wiregrass High Zephyrhills High
Please complete the following information listing three (3) 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
Provide Third Reference
If you are currently employed, please print the name and address of your work supervisor. If employed less than 6 months, the previous employer.
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 25 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.
H. I will adhere to all volunteer policies of my local school district.
I. I will notify Take Stock in Children if I must terminate my mentor position for any reason.
J. I will notify my student or his or her school liaison or the Take Stock in Children Student Advocate if I am unable to attend a previously scheduled meeting.
K. I will not willfully arrange contact with my student off school property and not under the supervision of Take Stock in Children or School Officials.
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.
I, the undersigned, certify, represent and warrant that I am a Take Stock in Children Mentor. For good and valuable consideration, the receipt of which is hereby acknowledged, the undersigned (“I” or “me”), as the Mentor hereby irrevocably authorizes Take Stock in Children, Inc., TSIC, Inc. d/b/a Take Stock in Children (“TSIC”) and each of their respective representatives, licensees, successors and assigns and those acting with authorization from Take Stock in Children – Pasco County (the “Lead Agency”) or TSIC (collectively, the “TSIC Program Providers”) to film, videotape, photograph and/or record my image and I irrevocably grant the right and authorize each of them to store, reproduce, edit and create derivative works based upon such film, videotape, photography and/or recording (collectively, the “Works”), as well as display, publicly, distribute, transmit or otherwise use the Works and my voice, name and likeness, in whole or in part, either alone or in conjunction with other material in or in connection with the Take Stock in Children Program’s events, products and services, as well as in advertising and promotion thereof in any form or format which may be reproduced, distributed, transmitted, exhibited and/or otherwise exploited, in whole or in part, alone or in conjunction with other material for the TSIC Program Providers’ own account in perpetuity throughout the world in any and all manner or media now known or hereafter devised including, without limitation, all forms of television, radio, print and the Internet.
I acknowledge and agree that as between myself and the TSIC Program Providers, the TSIC Program Providers shall exclusively own any and all rights in the Works and all elements thereof including, without limitation, all rights of attribution, moral rights and copyrights throughout the world in perpetuity. For avoidance of doubt, I hereby irrevocably assign to the TSIC Program Providers any and all rights I may have in and to the Works as well as any results and proceeds of such Works or my appearance in the Works. I agree not to use, reproduce, distribute or otherwise exploit the Works myself or authorize others to do so without the TSIC Program Providers’ prior written consent.
I hereby irrevocably release the TSIC Program Providers from, and agree not to assert, any and all claims I have or may have in the future, known or unknown arising for such use including, without limitation, claims of invasion of privacy, violation of right of publicity, defamation, false light, moral rights, royalties or other compensation or any other claims and waive any and all equitable or injunctive. The TSIC Program Providers shall not be obligated to make any payment to me for the use of my name, likeness, appearance, voice or other attributes in the Works or their exploitation, to produce or exploit the Works or to include my appearance therein even if produced and neither I shall have any right to review or approve any of Works or their use. I certify and acknowledge that my appearance is not governed under the provisions of any collective bargaining agreement. I represent and warrant that I am over eighteen (18) years of age and have all necessary capacity, power and authority to grant this release and that no consent or authorization is required to be obtained in order for me to grant this release. I agree to indemnify and hold the TSIC Program Providers harmless from and against any claim, liability or obligation of any kind arising from the statements made by me in the Works, my appearance in the Works, use of my name, voice, likeness and the rights granted herein, or any a breach of any of the representations and warranties made hereunder. This grant is irrevocable, perpetual, worldwide, transferable and licensable to others. This Consent and Release is governed by Florida law and contains the entire understanding of the parties, may not be changed or terminated except by an instrument signed by the TSIC Program Providers and me.
Applicant Electronic Signature (required)
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