Volunteer Your Time Application

I WANT TO BE A MENTOR

* Required Field

Last name:

First name:

Title:

Email:

Company Name:

Telephone:

Address:

State:

Zip:

City:

Ethnicity

Gender

Age

Have you ever been convicted of a crime?

Periodic Availability

Daily Availability

Length of Committment

THE MENTOR STATEMENT

I understand that being a mentor is an undertaking requiring responsibility, integrity, patience, and commitment.

I understand the need to provide references and hereby give permission for Genesis Consulting, LLC to contact those references.

I understand that Genesis Consulting, LLC will also conduct criminal background check on me.

I release Genesis Consulting, LLC, its officers, directors, employees, agents, and representatives from any and all liability whatsoever relating to the disclosure or use of my criminal offender record obtained, if any, pursuant to the State laws or other laws.

I also hereby release and agree to hold harmless from liability any person or organization that provides information concerning me to Genesis Consulting, LLC.

I understand that all of the information that I have provided may be verified.

I certify that all the statements made in this application are true,correct, and complete to the best of my knowledge and are made in good faith.

I understand that if any of the above information changes on my application that I  am responsible to inform Genesis Consulting, LLC in writing of those changes as soon as they occur.

I understand that any misinformation may be cause for disqualification or termination.

By submitting this application I am acknowledging that I have read and agree to the terms outlined above.

By submitting this application I am acknowledging that
I have read and agree to the terms outlined above.

ADDITIONAL COMMENTS & QUESTIONS