Mentor Application-Heart Gallery of Lane County

Heart Gallery of Lane County - A Family for Every Child

A Family For Every Child
Heart Gallery
541-343-2856
877-343-2856 christy@afamilyforeverychild.org

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Tax I.D. 20-4151057
Christy Obie~Barrett
Executive Director
880 Beltline Road
Springfield, OR 97477
fax 541-343-2866

OUR MISSION:
To find loving, permanent families for every waiting foster child.

Mentor Program Volunteer Application

Heart Gallery Mentor Program
880 Beltline Road.
Springfield OR 97477

ATTENTION: MENTOR DIRECTOR

First Name, MI.:

Last Name:

Address:

Apt #:

City:

State:

Zip Code:

Home Phone:

Message Phone:

Cell Phone:

Work Phone:

(REQUIRED) Email:

Social S. Number:

Birthday:

Gender: F M

What are your interests, skills, and hobbies?:

Artistic/crafts Bilingual (language) Office Work Computer Work

Reading Education Writing Home Skills

Please list other hobbies, skills, and interests:

How did you hear about Heart Gallery Mentor Program?

What days and times are you available?

Do you need accommodations to perform volunteer services? Yes No
If yes, please explain.

Personal References: Three references are required. References should have known
you for at least one year. Please do not include relatives or members of your household.
Please fill out completely; incomplete information will delay the processing of your
application.

Reference #1

First and Last Name

Mailing Address

City, State, and Zip

Email Address

Phone

Relationship:

How long:

Reference #2

First and Last Name

Mailing Address

City, State, and Zip

Email Address

Phone

Relationship:

How long:

Reference #3

First and Last Name

Mailing Address

City, State, and Zip

Email Address

Phone

Relationship:

How long:

Mentor Program Emergency Contacts


Emergency Contact #1:		Relationship:
Address:		Phone:
		Other Info:

Emergency Contact #2:		Relationship:
Address:		Phone:
		Other Info:
Mentor Program Volunteer Information Form

First Name:		Last Name:
Address:		City, State, Zip Code:
Phone:		(REQUIRED) Volunteer email:

1. Why are you interested in volunteering or being a Heart Gallery Mentor?

2. Why did you choose Heart Gallery Mentor Program, a program that works specifically with teenage foster youth?

3. What do you like to do in your free time?

4. How would you describe yourself?

5. Please tell us any circumstances in which you would be uncomfortable working with a young adult (i.e. if the young adult has experienced abuse, drug and alcohol issues, grief, and loss, etc.).

6. Is there anything else you think would be important for us to know about you or that you would like to add?

7. Is there any part of Independent Living skills that you feel you would like to help teach or educate a group about (i.e. banking, car care, study groups, applications, interviewing, job skills, resumes, apartment and housing, daily living skills (laundry, cooking, simple repairs) and all other tasks that a young adult will need to know how to do? (This can be a class, a flyer, a hands on event, a publication for ILP binder, video what ever you would want to put together (even if it is only a small part of the complete task).

Mentor Program Volunteer Release Form

Purpose: To provide a framework wherein volunteers understand the context in which
they might interact with Heart Gallery Mentor Program participants.
Please check the boxes to indicate that you have read and understood each item below on the release form.

First Name:		Last Name:
Address:		City, State, Zip:
Phone:		(REQUIRED) Email:

	I understand that while I am a volunteer with Heart Gallery Mentor Program I will be working with participates that are legally adults and others who are minors.
	I will not hold Heart Gallery Mentor Program responsible for the actions of the participants with whom I may interact with. I will not hold Heart Gallery Mentor Program responsible for loss of property or damage resulting from actions of the participants in the program.
	I assume responsibility for the activities and locations in which I involve myself with participants and do not hold Heart Gallery Mentor Program responsible for events that may occur there.
	I accept and assume responsibility for any and all risks of personal damage or injury which occur during activities or resulting from my participation as a volunteer in Heart Gallery Mentor Program.
	I agree to inform Heart Gallery Mentor Program staff of any concerns regarding incidences involving participants in the program or that might impact the program itself. I also understand that I am mandated by law to report suspected abuse/ and or neglect that I may be aware of involving minors served by Heart Gallery Mentor Program.
	I understand that Heart Gallery Mentor Program is a drug and alcohol free program and I understand that I should refrain from the use of such substances when participating in Heart Gallery Mentor Program activities and events.
	I understand that Heart Gallery Mentor Program will make reasonable efforts to inform me of any concerns that could pose risks to volunteers but further acknowledge Heart Gallery Mentor Program can not prevent all incidents from occurring.
	I understand that I have to attend 2 out of 3 trainings per year to continue the Heart Gallery Mentor Program.
	I agree to complete and submit a monthly report to the mentor director stating my activities involving my youth, by the last day of the month.
	I give Heart Gallery Mentor Program permission to use my written quotation or picture in a replicated fashion in a brochure, pamphlet, flyer or informational publication designed to promote or enhance the Heart Gallery Mentor Program. This release may be revoked at anytime.

FINGERPRINT OPTIONS:
Sheriff's Dept. 125 E. 8th Ave. Rm. 140
Eugene OR
Mon-Fri / 9 am to 5 pm
541-686-3906-No Appointment necessary
$12.00

Eugene Vocational School
805 Wilson
Next to B & H Upholstery
Eugene OR
Mon-Fri / 9:00am-noon & 1:00pm to 5pm
No Appointment necessary
$15.00

I certify that all statements contained herein are true and complete whether made by me or others at my request.