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Steps

1. Step One This section is complete This section is incomplete
2. Statement of Agreement This section is complete This section is incomplete
3. Mentor Survey This section is complete This section is incomplete

Step One

Full Legal Name*
Date*
Date
Home Address*
City*
State*
Zip*
Mailing Address
If different than above
City
State
Zip
Phone Type*
Phone Number*
Best Time to Contact You*
Education and Employment
Highest Level of Education Earned*
Current Employer*
Current Position*
Employer Address*
City
State
Zip
Special Skills or Training*
Foreign Language?*
References
Please list three references including email and phone number so that we may contact them (no relatives).
Reference 1 Name*
Relationship to You*
Email*
Phone*
Reference 2 Name*
Relationship to You*
Email*
Phone*
Reference 3 Name*
Relationship to You*
Email*
Phone*
Emergency Contact*
Phone*
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Statement of Agreement

Instructions
Please fill out the form below. A criminal background check is also required as a precautionary measure in protection of the Aspire Mentoring Program, the children/families we serve, and the city of Longview. That form will be completed at New Mentor Orientation. Read each statement, select, "Yes", and indicate agreement by your signature below.
Statement 1*
I agree not to consume, use, possess, or be under the influence of any drug or alcohol products while volunteering for the City of Longview.
Statement 2*
I understand that any conduct or pattern of conduct that would tend to disrupt, diminish, or otherwise jeopardize public trust in the City of Longview will result in dismissal.
Statement 3*
I understand that my volunteer assignment with the City of Longview may be terminated at any time.
Statement 4*
I understand that depending upon the nature of the volunteer assignment, the City of Longview may deem it necessary to obtain a Driver's License Record and/or a Criminal Conviction History and Wanted Information Reports on individuals volunteering for the City of Longview. I hereby consent to the City of Longview to make any requests for a Drivers License Record, a Criminal History Report, and/or a Wanted Information Report on me. I release, relinquish, and remise the City of Longview, its employees,agents, and representatives, from any and all causes of action or liability which I may have or which arise out of, or as a result of, the reports herein authorized. Furthermore, I understand that my failure to execute this informed consent will result in my not being further considered for employment or volunteerism.
Statement 5*
I have NOT been convicted and/or placed on probation for any criminal offense.
Statement 5 - Addendum 1
If you HAVE been convicted and/or placed on probation, please list date and nature of offense.
Previous Addresses*
List any states you have lived in besides Texas and how long you resided there.
E-Signature*
Date
Date
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Aspire Mentoring Program Application and Survey

Steps

Step One

Statement of Agreement

Mentor Survey

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