Partner/Mentor application

Form for Partner/Mentor application

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This field is for validation purposes and should be left unchanged.

Are you applying to be a Partner or a Mentor?(Required)

Name(Required)

First Last

Which High School are you interested in mentoring at?(Required)

Roselle Catholic High School (Roselle, NJ)

St. Benedict’s Prep (Newark, NJ)

St. Vincent Academy (Newark, NJ)

Hudson Catholic High School (Jersey City, NJ)

St. Dominic Academy (Jersey City, NJ)

No Preference

Date of Birth (minimum age of 21 to be a S/PA mentor):(Required)

Cell Phone(Required)

Personal Email(Required)

Address(Required)

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

Have you moved in last 5 years?(Required)

Previous address (if you moved within the past 5 years)(Required)

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

Emergency Contact Name:(Required)

Emergency Contact Cell Phone Number:(Required)

Referred By:

Current Employer:

Job Title:

Start Date:(Required)

Is there any other prior work experience that you would like to share with us?(Required)

What was your major?(Required)

Where did you attend college?(Required)

What year did you graduate college?(Required)

What year did you graduate High School?(Required)

Where did you attend High School?(Required)

Why are you interested in becoming a mentor with S/PA? Is there any particular aspect that resonates with you?(Required)

What skills, interests or hobbies do you possess that would be helpful to a high school student?(Required)

Have you ever been convicted of any crimes or felonies?(Required)

Are you or have you ever been the subject of an indicted child abuse and malreatment report on file with any Registry of Child Abuse and Maltreatment, or have you been penalized for maltreatment of a child?(Required)

Reference 1 Name:(Required)

Email:(Required)

Phone:(Required)

Reference 2 Name:(Required)

Email:(Required)

Phone:(Required)

Reference 3 Name:(Required)

Email:(Required)

Phone:(Required)

Declarations(Required)

Student/Partner Alliance appreciates your willingness to mentor inner-city high school students. Providing safe and secure programs for our students is of utmost importance to us. S/PA does not discriminate based on an individual’s sex, race, color, ethnicity, national origin, age, disability, religion, sexual orientation, or any other legally protected characteristic. The information gathered in this application is designed to help us provide the highest quality programs for the people of our community. Please read and sign below to grant your consent to all of the following statements.

I hereby authorize Student/Partner Alliance (S/PA) to conduct a personal and professional background check for the purposes of my application at S/PA. S/PA may contact any references, past and current employers, church, youth organizations, agencies where volunteer service has been completed, and any individual or organization which might be relevant to my desired position. I hereby release all of the above stated persons from any and all liability for damages that might occur during S/PA’s contact with the individuals for purposes of volunteer services.

I also hereby give complete permission for S/PA to conduct a criminal background check, arrest records check, abuse registry check, and driving record check for the purposes of my volunteer services, and agree to cooperate as necessary with the background screening process. I authorize investigations of all statements contained in the application.

I understand and agree that information may be obtained from sources that I provided above and that this information will be held confidentially by S/PA and not revealed to me. I have also read and understood the above stated information within this release and am signing below of my own free will.

I agree to observe all of the S/PA guidelines and policies for the program in which I am applying.
I understand that S/PA has a ZERO TOLERANCE FOR ABUSE and takes all allegations of abuse seriously. I further understand that S/PA cooperates fully with the authorities to investigate all cases of alleged abuse. Abuse of minors or vulnerable adults is grounds for immediate dismissal and possible criminal charges.

I understand that I can withdraw from the application process at any time.

I agree to abide by the following, to:

-Exhibit the highest ethical standards and personal integrity.

-Not take advantage of a counseling, supervisory and/or authoritative relationship for their own benefit.

-Not abuse, harass or neglect a minor or an adult.

-Share concerns about suspicious or inappropriate behavior with any staff member of S/PA.

-Adhere to the requirements of the law of the State of New Jersey regarding the reporting of any suspected abuse of a minor.

-Accept personal responsibility in the protection of minors and adults from all forms of abuse.

PHOTO AND NAME RELEASE

By participating in the Student/Partner Alliance (S/PA) program, or in a S/PA – sponsored event, I consent to the use of my photograph, likeness and name in any materials (including by way of illustration and limitation, print, website, digital, mobile and other publications and communications) that describe or promote S/PA. I also understand and agree that no royalty, fee or other compensation shall be payable to me by reason of any such use.

Acknowledgement

My signature indicates that I have read, understand and agree to abide by the above and I declare that all statements contained in this application are true. (Do not sign until you have read the above statements.) In signing this document, I agree to hold Student/Partner Alliance harmless and release from all claims.

I confirm that I have read and understood the terms outlined above.

Signature:(Required)

Date(Required)