FAMILY SERVICES OF CENTRAL ALBERTA
5409 - 50th Avenue
Red Deer, AB T4N 4B7
Phone: 403-343-6400   Fax: 403-343-6407


VOLUNTEER MENTOR APPLICATION FORM
This initiative is in partnership with the High Risk Youth Coalition and its affiliated agencies.


Adult:   Youth:


First Name:
Last Name:
Street Address:
City:
Province:
Postal Code:

Daytime Phone:
Business/Cell Phone:
E-mail Address:


I prefer to be contacted by:


Occupation:


EDUCATION HISTORY

Highest level of education completed:

High School
College/University
Trade/Business
Other:



EMPLOYMENT HISTORY

Please provide your employment history - including company name, dates worked, brief description of responsibilities:


VOLUNTEER HISTORY

How often can you commit to volunteer? Weekly   Monthly   Not Sure


Check off which skills and experience you have to offer:

CPR
First Aid
Coaching
Experience working with youth
Second Language - specify:


Check off your talents and interests:

Photography Art Music
Science Reading Sports Animals
Cooking Dancing Movies Yoga/Pilates
Specify any other talents and/or interests:


Check off your main reason for volunteering:

Academic Credit Social Interaction Employment Experience
Learn new skills Help Others You know what it's like to be a vulnerable youth
Other reasons for volunteering:


Check off how you found about the mentorship program:

Friend/Relative Visit to FSCA High Risk Youth Coalition
Volunteer Poster/Brochure School
Newspaper Local Agency FSCA Website Other Website


Please indicate the days and times you are available to volunteer:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning
Afternoon
Evening


Any physical limitations, medical conditions or allergies that may affect your attendance or performance:

Are you currently volunteering elsewhere? Yes No   If yes, where?


Please provide your volunteer history - including organization, dates worked, brief description of responsibilities:


EMERGENCY CONTACT INFORMATION
Name:
Address:
Phone Number:
Relationship:


REFERENCES:
Name: Name:
Address: Address:
Phone Number: Phone Number:
Relationship: Relationship:


Declaration:
I hereby declare that the above information is true and complete to the best of my knowledge. I understand that a false statement may disqualify me from further consideration as a volunteer or result in dismissal.

Authorization for collection of personal information:
I authorized Family Services of Central Alberta to collect personal information appropriate to the opportunities applied for concerning my academic background and employment history, and to verify the character references I have supplied. Family Services of Central Alberta adheres to the Protection of Privacy Act and the Freedom of Information and Protection of Privacy Act.

Consent to share personal information with collaborating agencies:
I understand that, should I be a successful applicant, my name and personal information will appear in a "bank" or qualified mentors which collaborating community agencies will be able to access as needs arise. Volunteer screening and management of this "bank" will be the responsibility of Family Services of Central Alberta, however, mentorship hours may occur under the supervision of another local community agency or group.

I understand that:
A Police Record Search is required for potential volunteers who are applying for positions that are considered to have, or potentially have, interaction or contact with children, youth and other vulnerable groups. Volunteer placement is made on the basis of the program requirements, the skills, and experience of the applicant and, when appropriate, successful reference checks and a police record search.


Thank you for your application. You will be contacted for notification that your application was received an with further details regarding the screening process. Please note that due to the group that volunteers will be working with, not all applicants maybe a fit and applying does not guarantee placement. Thank you for your interest in volunteering in our community.


"We cannot always build the future for our youth, but we can build our youth for the future."
~Franklin D. Roosevelt~



Signature:   Date: