1-877-HORSE10 info@hhhusa.org

HHH Mentor Application

Once received, we will contact your references listed; please let them know to expect a call or e-mail from a Horses Healing Hearts representative. At this time we will also conduct a background check, including but not limited to driving record checks, criminal background checks, and other records required by local, state, or federal law for volunteers working with youth. You will automatically be determined to be ineligible if you have ever been accused of, charged, or convicted of any form of child abuse. You may also be determined ineligible based on information resulting from background checks, driving record check, and other checks required by local, state, or federal law for volunteers working with youth.

 

Name

Address

Previous Address

Phone

Email

Drivers License Number

Drivers License State Issued and Expiration Date

Employer or School Name

Employer or School Address

Race

Ethnicity

Please list 3 references that you have known for at least one year and that are not related to you. Please include their full name, their phone number, email address and state they reside.

References area

Please list the name, date of birth and relationship for the people in your household.

Household Members

Have you ever been arrested?

Please list below any organizations you have volunteered/worked for in the past. Please be sure to include the agency name, a contact person, phone number, and date of involvement.

Organizations

Please list below any extra-curricular activites you were/are involved in. Please be sure to include group/club, coach/staff, phone number and dates of involvement.

Extra-Curricular Activites

Please list any faith based organizations or any other organizations that you wish to include. Please include the following: agency name, contact name, phone number and dates of involvement.

STATEMENT OF UNDERSTANDING AND AUTHORIZATION

The Big Brothers Big Sisters mentoring programs are interfaith and interracial programs. Horses Healing Hearts does not discriminate in any way. However, the desires of the child’s parent or guardian are respected in the selection of an appropriate adult mentor for each child. The agency will share any information relevant to the match with the parent or guardian, while withholding the volunteer’s name until the physical match is made. Any party has the right to refuse to enter into the match based upon information communicated by the agency staff. I also give HHH permision to contaact the organizations that I have volunteered/participated in the past. I confirm all information is accurate and ready to be processed.

I understand that:
1) The references I listed may be contacted by telephone, e-mail, or mail;
2) This in no way obligates me to perform any volunteer services;
3) The information I provided of myself and household members will be used to conduct a background check, including but not limited to driving records checks, criminal background checks, and other records required by local, state, or federal law for volunteers working with youth;
4) That HHH is not obligated to match me with a youth, and should the agency decide not to match me with a child, the reasoning will not be disclosed.
5) As a part of the HHH enrollment processes, I may be asked to provide additional personal information prior to a recommendation for a match.

I understand the Statement of Understanding and Authorization and agree to its terms. I confirm that all information provided in this application is true.

Signature

Date