Break The Cycle Mentorship Application

Volunteer Experience

Your Availability

Employment History

References

(Provide 2-3 personal or professional, not a relative)

Reference #2

Reference #3

IN CASE OF AN EMERGENCY PLEASE NOTIFY

Criminal History

Have you ever been convicted of a misdemeanor or felony, or are any misdemeanor or felony charges pending against you? If yes, please explain below. (Note: Answering yes will not automatically prohibit individuals from becoming volunteers, but will be considered with respect to time, circumstances, seriousness and relationship to volunteer responsibilities). This volunteer position does require a background check. you will be provided with a separate criminal background check authorization form.

My signature below certifies that all statements made on this application are true, complete and correct to the best of my knowledge and belief. I understand these statements are subject to verification. I understand that falsification on this application can disqualify me from consideration or result in my volunteer services being denied. Furthermore, my signature below provides my authorization to Break The Cycle Today to conduct driver license and motor vehicle record checks as needed, as well as reference checks to determine my suitability for placement.

I hereby release all parties from any liability for furnishing this information.

Break The Cycle Today acknowledges that equal opportunity for all persons is a fundamental human value. Each volunteer applicant will be considered on the basis of individual ability and merit, without regard to race, color, age, religion, national origin, disability, sexual orientation, sex, or marital status.