Mentring and Caching Interventin Preventin Prgrams Mentring Caching Mentr Applicatin Prcess Rles and Respnsibilities Our Mentring Caching Prgram strives t develp a strng bnd and a cnsistent relatinship between a qualified mentr and a fster yuth. Ptential Mentrs are required t g thrugh the screening prcess as detailed belw. Csts related t the applicatin prcess will be paid/ reimbursed by Sutter Cunty Superintendent f Schls- Interventin Preventin Prgrams (IPP). Step 1: Pre-Selectin Prcess: Sutter Cunty Superintendent f Schls Human Resurces Department Vlunteer applicatin (page 3 and 4 f this packet) Livescan fingerprinting frm Tuberculsis (TB) test results Clearance frm DMV driver s license recrd and prf f aut insurance frm Sutter Cunty Superintendent f Schls- Interventin Preventin Prgrams (IPP) Mentr Matching Infrmatin frm (page 5 f this packet) Step 2: Mentr Matching: Cntact persnal references Oral Interview Review Mentr Matching Infrmatin frm True Clrs Persnality Assessment Attend a minimum f fur hurs f mentr training and develpment Step 3: Mentr Cmmitment: One schl semester( 15 weeks) A minimum f tw hurs per mnth Weekly phne cntact Step 4: Pst-Selectin Fllw-Up: Minimum weekly cntact with IPP staff t mnitr relatinship prgress Cmplete mnthly tracking frms Final 2 Page
Bill Crnelius, Superintendent 970 Klamath Lane Yuba City, CA 95993 (530) 822-2900 Fax (530) 671-3422 VOLUNTEER APPLICATION Vlunteer Assignment: Schl Site: Reasn fr vlunteering: PERSONAL INFORMATION LAST NAME FIRST M.I. STREET ADDRESS P.O. BOX DAYTIME PHONE CITY, STATE, ZIP EVENING PHONE SOCIAL SECURITY NUMBER (NOTE: Scial Security Number is ptinal.) What hurs/days are yu available as a vlunteer? Are any criminal charges r prceedings pending against yu? YES NO If yes, please explain belw. Have yu ever been cnvicted f any misdemeanr r felny? YES NO dispsitin f case(s) belw. If yes, please explain when, where, and D yu have any relatives wh wrk fr Sutter Cunty Superintendent f Schls? Yes NO EMERGENCY CONTACT Persn t cntact in case f emergency: Hme Telephne Number: Office Telephne Number:
SPECIAL SKILLS Summarize special skills and/r hbbies. REFERENCES Please list references wh can verify yur current r past wrk/vlunteer experience (past/present supervisr, instructrs, minister, etc.) NAME OF REFERENCE ORGANIZATION/POSITION HOW LONG ASSOCIATED? 1. PHONE NUMBER 2. 3. 4. My signature belw authrizes the schl district/cunty ffice f educatin t cnduct a backgrund investigatin and authrizes release f all infrmatin in cnnectin with my vlunteer applicatin. Further, I hld harmless any individual r firm fr any infrmatin that they may prvide in this investigatin which may include such infrmatin as criminal r civil cnvictins, driving recrds, previus emplyers and educatinal institutins, persnal references, prfessinal references and ther apprpriate surces. I waive my right f access t any such infrmatin, and withut limitatin, hereby release the schl district/cunty ffice f educatin and the reference surce frm any and all liability in cnnectin with its release r use. This release includes the surces cited abve and specific examples as fllws: Law enfrcement agencies and any Lcality t which they may refer fr release f infrmatin pertaining t any finds f child abuse r neglect investigatins invlving me. Furthermre, I certify that I have made true, crrect, and cmplete answers and statements n this applicatin in the knwledge that they may be relied upn in cnsidering my applicatin. As a vlunteer I agree t: 1) fllw the rules and regulatins f Sutter Cunty Superintendent f Schls, 2) t be free f the influence f alchl r illegal drugs, 3) t never purpsefully endanger the life r health f a student r emplyee, 3) t be fingerprinted and shw prf f negative tuberculsis. Date: Signature: Fr Office Use Only EMPLOYABILITY STATUS Eligible (N criminal histry) Eligible (Criminal histry summary cntains ffences ther than thse prhibiting emplyment) Ineligible Date Criminal Histry Received frm DOJ: / / Mnth Day Year I certify under penalty f perjury, that a Department f Justice criminal recrd summary has been btained n the abve named applicant and that the said Applicant and that the said applicant s emplyability status has been determined by the criteria enumerated in the Califrnia Educatin cde relating t emplyment by a public cunty ffice f educatin. Schl Office Designee Date
Mentring and Caching Interventin Preventin Prgrams Mentring Caching 1) Hw d yu spend yur spare time? Mentr Matching Infrmatin 2) What activities d yu enjy? 3) D yu belng t any clubs r rganizatins? 4) Please prvide a Persnal Statement as t why yu wuld like t be a Mentr t fster yuth. (500 wrds r less, attach additinal paper, if needed) Final 5 Page