E34 Mentoring

E34 Mentoring Application

2023-2024

E34 is our mentoring program here at Urban Youth Impact. Our mission is to empower students with the love of Christ by doing life together as we build into them spiritually, physically, and socially.

E34 is short for Ezekiel chapter 34. In this passage, God is calling His people to action and challenging us to go out and care for His sheep. It is our responsibility as believers to take care of those around us, especially the little ones. Children hold a special place in God's heart and therefore should hold a special place in our heart, as well.

Contact Information

Name

Street Address

City, State

Zip Code

Phone Number

Is this your mobile number?

Yes No

Are you willing to receive text communication from E34?

Yes No

Email Address

Emergency Contact Name

Emergency Contact Phone Number

Education

High School (Name, City, State)

Did you graduate?

Yes No

College, if applicable (Name, City, State)

Major

Did you graduate?

Yes No

Are you currently a full time student?

Yes No

Current Employer

Employer

Your Title/Position

Address (Street, City, State, Zip)

Supervisor Name

Phone Number

Email Address

References

Please include a reference from a church leader and a reference from a friend, preferably a Christian, who has known you for more than one year.

Church Leader

Name

Title/Position

Phone Number

Email address

Relationship

Personal Reference (non-family member, spouse, or significant other)

Name

Phone Number

Email address

Relationship

Please Answer the Following Questions
We would like to learn about your interest in serving in this ministry, your understanding of the Bible, and your walk with God.

How did you hear about Urban Youth Impact?

What is your primary reason for wanting to serve with Urban Youth Impact?

How much time are you willing to pledge to mentor a child?

Do you already have a child in mind to mentor?

YesNo

What is their full name, age and affiliation with UYI?

How did you come to know them?

Do you regularly attend a small group, Bible Study or serve in any capacity at a local church?

YesNo

What church and in what capacity?

Have you previously served in the inner city in any way? If so, how?

How would you describe yourself?

How did you come to know Jesus Christ as your Lord and Savior?

Are you currently being discipled by anyone?

Do you believe the Bible is the infallible Word of God? Why or why not?

How do you define ministry?

How do you define a servant's heart?

Read and reflect on 1 Timothy 3. Do you believe you meet the requirements of a leader?

How do you define repentance? What does repentance look like in your life?

What was the last thing God called you to do that you acted on (your last step of faith)?

What is one thing you believe God may be calling you to do now (your next step of faith)?

How is the Lord currently working in your life?

What are some areas of your life in which you want to see transformation?

What are your spiritual gifts?

What are some of your strengths and weaknesses?

What are your hobbies?

Is there anything else you would like us to know about you?

CONFIDENTIAL INFORMATION

Please answer the following questions honestly. Your answers will not automatically disqualify you from being a volunteer at Urban Youth Impact.

Have you ever been arrested or convicted of a misdemeanor or felony?

Yes No

What was the charge? Where (city, county, state)? What year?

Have you ever been formally accused of child abuse?

Yes No

Please explain.

Have you ever received psychiatric care?

Yes No

Please explain.

Have you ever struggled with addiction to illegal or prescription drugs?

YesNo

Please explain.

Do you consume alcohol?

Yes No

How often do you drink and in what situations?

BACKGROUND CHECKS

Please be advised that Urban Youth Impact reserves the right to perform county, state, and federal background checks on every Volunteer Mentor. We take the protection of our children very seriously.

I hereby authorize, without reservation, the obtaining of “consumer reports” or “investigative consumer” reports by Urban Youth Impact at any time after receipt of this authorization and throughout my employment or volunteer service, if applicable. I further authorize and request, without reservation, any present or former employer, school, police department, state or federal agency, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about me to furnish LexisNexis or Urban Youth Impact with any and all background information in their possession regarding me, so that my employment qualifications may be evaluated and/or reassessed. I also agree that a fax or photocopy of this authorization with my signature should have the same authority as the original.

By signing below, I certify that: (1) I have read and fully understand this disclosure and authorization; (2) all of the information I am providing is true, complete, correct, and accurate; and (3) I have received the attached Summary of Your Rights under the Fair Credit Reporting Act (15 U.S.C. §1681 et seq.).

Full Legal Name

Date of Birth (MM/DD/YYYY)

Social Security Number

Driver's License Number

Street Address

City

State

Zip

Other Names (e.g., maiden name, married name, surnames, etc.)

Please list all counties and states you have lived in since the age of 18, including dates.

Volunteer Mentor Name

Volunteer Mentor Signature (Full Name to act as signature)

Date

***The following is information required in order for Urban Youth Impact to obtain a complete consumer report. This information will be used for background screening purposes only.

DISCLOSURE
In connection with your application for employment or volunteer service with Urban Youth Impact (including any independent contract for services) or when deciding whether to modify or continue your ongoing employment (if hired) or service, Urban Youth Impact, may obtain a “consumer report” and/or an “investigative consumer report” on you from LexisNexis, a consumer reporting agency, or from any third party, in strict compliance with both state and federal law.
A consumer report is a communication of information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used for purposes of serving as a factor in establishing your current and/or continuing eligibility for employment purposes.
An investigative consumer report is a report obtained through personal interviews with individuals who may have knowledge of your character, general reputation, personal characteristics, or mode of living. The consumer reports or investigative consumer reports may contain information regarding your credit history (if applicable to position), criminal records, driving history records, education records, previous employment history, social security traces, military records, professional licensure records, drug testing, government records, and other types of background information.
You further understand that these reports may contain information concerning the reasons for termination of past employment. You are hereby notified that you have the right to make a timely request for the nature and scope of any investigative consumer report. You are further notified that, prior to being denied employment based in the whole or in part on information obtained in the consumer report, you will be provided a copy of the report, the name, address, and telephone number of the consumer reporting agency and a description in writing of your right under the Fair Credit Reporting Act. Inquires to LexisNexis should be directed to LexisNexis.

CRIMINAL RECORD HISTORY
Please answer the following questions truthfully. If you answer "Yes" to any of the questions, please include an explanation.

Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (excluding minor traffic violations)

Yes No

Please explain.

Have you ever received deferred adjudication or similar disposition for any federal, state or municipal criminal offense?

Yes No

Please explain.

Have you ever received probation or community supervision for any federal, state, or municipal criminal offense?

Yes No

Please explain.

Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?

Yes No

Please explain.

As of the date of this authorization, do you have any pending criminal charges against you?

Yes No

Please explain.

Have you ever served in the United States Military?

Yes No

Did you receive an honorable discharge?

Yes No

Please explain.

Did you receive a DD214 and would you be able to present this document?

Yes No

VOLUNTEER WAIVER

I understand and affirm under oath to the truthfulness of the claims made herein and that the punishment for knowingly making a false statement includes fines and/or imprisonment. Under penalties of perjury, I declare that I have read the foregoing and the facts alleged are true to the best of my knowledge and belief.

Volunteer Mentor Name

Date

Volunteer Mentor Signature (Full name to act as signature)

RELEASE OF CONTACT INFORMATION
I understand that my phone number and email may be shared with other volunteers serving in the same ministry for replacement purposes if they need to find someone to switch weeks with them.

Volunteer Mentor Name

Date

Volunteer Mentor Signature (Full name to act as signature)

E34 Mentoring

E34 Mentoring Application

Contact Information

Education

Current Employer

References

Please Answer the Following QuestionsWe would like to learn about your interest in serving in this ministry, your understanding of the Bible, and your walk with God.

CRIMINAL RECORD HISTORYPlease answer the following questions truthfully. If you answer "Yes" to any of the questions, please include an explanation.

VOLUNTEER WAIVER

RELEASE OF CONTACT INFORMATIONI understand that my phone number and email may be shared with other volunteers serving in the same ministry for replacement purposes if they need to find someone to switch weeks with them.

Please Answer the Following Questions
We would like to learn about your interest in serving in this ministry, your understanding of the Bible, and your walk with God.

CRIMINAL RECORD HISTORY
Please answer the following questions truthfully. If you answer "Yes" to any of the questions, please include an explanation.

RELEASE OF CONTACT INFORMATION
I understand that my phone number and email may be shared with other volunteers serving in the same ministry for replacement purposes if they need to find someone to switch weeks with them.