If you are interested in becoming a mentor, please fill out the following form.
First Name
Last Name
Birth Date
Gender MaleFemale
Street Address
City
Province
Postal Code
Phone
Email
I prefer to work with a child in: Middle School (Gr. 6-8)High School (Gr. 9-12)
Please write a brief statement on why you wish to be a mentor:
What is your availability? Are you able to commit to spending 2 hours per week with your mentee for at least a year?
What are some of your interests or hobbies? This information is helpful when matching you with your mentee.
Please provide 3 references (non-family members). Please include their name, contact information, and your relationship to them:
Mentor Release Statement
(adapted from Foundations of Successful Youth Mentoring sample statement)
I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of the Swift Current Community Youth Initiative Mentoring Program. I undersign that the program involves spending a minimum of ______ hour(s)/week at a location as decided with the mentee or mentee’s guardian. Further, I understand that I will complete a training session, keep in regular contact with my mentee, and communicate with staff of the SCCYI regularly during this period. I agree to have an open mind as I engage in a supportive relationship with the mentee. I agree to notify the Program Administrator if I am having difficulty connecting and building a relationship with my assigned mentee. I am willing to commit to one year in the program and then will be asked to renew for another year.
I agree to refrain from contacting or seeing my mentee outside of the established parameters of mentoring sessions unless otherwise directed.
I agree to notify the Program Administrator of any changes to my address and telephone number.
I will ensure confidentiality in carrying out the duties assigned to me as a volunteer/staff of The Center, and will comply with its policies and procedures. Except as I may be legally required, I will not disclose or give to any person not employed by, or functioning in an employee role, or a volunteer of The Center, any information or document of a confidential nature that comes to my knowledge or possession while performing these duties.
I have not been convicted within the past 10 years, of any felony or misdemeanour classified as an offence against a person or family related to any offences of the violent or sexual nature, of public indecency, or a violation involving a controlled substance. I am not under current indictment.
Further, I hereby release, discharge, and hold harmless the Swift Current Community Youth Initiative Mentoring Program, participating organizations, and all of the foregoing employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs and expenses which may be or may at any time hereafter become attributable to my participation in the Swift Current Community Youth Initiative Mentoring Program.
I understand that the Swift Current Community Youth Initiative staff reserves the right to terminate a mentor from the program. The program takes place within the confines of the program’s policies and does not encourage or approve of relationships established between mentor/mentee and family members beyond the organized and supervised activities of the program. I understand that the Swift Current Community Youth Initiative holds the right to complete a home safety check in my home if necessary. I give permission for program staff to conduct a criminal background check and/or vulnerable sector check as part of the screening for entrance into the program. This includes verification of personal and employment references. Program staff has final right of acceptance of an applicant into the program and reserves the right to terminate a mentor from the program at any time.
I have read the above release statement and by continuing, agree to the contents. By continuing I certify that all statements in this application are true and accurate.
