POLICE ATHLETIC LEAGUE
OF JACKSONVILLE, INC.
PAL MENTOR APPLICATION
Mentors must volunteer a minimum of one hour per week at a predetermined location.
Name of Applicant:
Date of Birth:
SS#:
Address:
City:
State:
Zip Code:
Home Telephone:
Email:
Employer:
Occupation:
Employer Address:
City:
State:
Zip Code:
Business Telephone:
Fax:
Best time of day to mentor (check all that apply):
Morning
Do you prefer to be matched with (check one):
I would like to work with (check one):
Younger youth (ages 9-14)
Boy
Girl
Older youth (15-18)
Afternoon
Evening
No Preference
No Preference
Please write a brief statement as to why you wish to be a mentor:
Describe special interests/hobbies which may be helpful in matching you with a mentee
(examples include: cooking, crafts, career interest, games, sports, computers, art, needle point ,
languages, music or painting)
Please list all addresses where you have resided in the last five years; begin with the most recent.
Do not list the current address above.
Dates: from ___________ to ______________
Address:
Dates: from ___________ to ______________
Address:
Please fax or mail this form to the PAL Mentoring Coordinator
Email: mentoring@jaxpal.com Fax: (904) 353-9071
POLICE ATHLETIC LEAGUE
OF JACKSONVILLE, INC.
MENTORING PERSONAL/EMPLOYMENT HISTORY
PERSONAL REFERENCES:
Please provide three personal references (non-family member).
1. Name: __________________________________ Relationship:_______________________________
Telephone: ___________________________
Email: ___________________________________
Address: ________________________________________________________________________
2. Name: __________________________________ Relationship:_______________________________
Telephone: ___________________________
Email: ___________________________________
Address: ________________________________________________________________________
3. Name: __________________________________ Relationship:_______________________________
Telephone: ___________________________
Email: ___________________________________
Address: ________________________________________________________________________
EMPLOYMENT HISTORY:
Please list the last three places of employment with the most recent first:
1. Company: ___________________________________________________________________________
Job Title: ________________________________________________________________________
Company Address: _______________________________________________________________
Phone: _______________ Dates of Employment: From ________________ to ______________
2. Company: ___________________________________________________________________________
Job Title: ________________________________________________________________________
Company Address: _______________________________________________________________
Phone: _______________ Dates of Employment: From ________________ to ______________
3. Company: ___________________________________________________________________________
Job Title: ________________________________________________________________________
Company Address: _______________________________________________________________
Phone: _______________ Dates of Employment: From ________________ to ______________
Please fax or mail this form to PAL Mentoring Coordinator
Email: mentoring@jaxpal.com Fax: (904) 353-9071
POLICE ATHLETIC LEAGUE
OF JACKSONVILLE, INC.
MENTOR AGREEMENT/RELEASE STATEMENT:
As a volunteer mentor in the Jacksonville PAL Mentoring Program, I _________________________,
agree to the following (Please initial):
Attend a training session before beginning in the program
Be on time for scheduled meetings
Notify the coordinator if the meeting must be cancelled
Engage in the relationship with an open mind
Accept assistance from PAL and its mentoring staff
Keep discussions with my mentee confidential
Ask staff when I need assistance or have questions
Notify the coordinator of any changes in my employment, address,
and telephone number.
Notify the PAL Mentor coordinator FIRST of any desire to terminate
the relationship with my mentee.
MENTOR RELEASE STATEMENT:
I, the undersigned, hereby state that if accepted as a mentor I agree to abide by the rules and regulations of the National PAL
Mentoring Program at the Jacksonville PAL chapter (hereafter known as the chapter). I understand that the program involves
spending a minimum of one hour per week at the chapter. I am not allowed to take youth away from the chapter’s designated
meeting place without the permission of the Chaptor Mentorign Program Coordinator. Further, I understand that I will attend a
mentor training session, maintain regular contact with my mentee and communicate with PAL staff regularly during this period. I
am willing to commit to one year in the program with the potential of renewing my obligation for more years.
I have not been convicted, within the past ten years, of any felony or misdemeanor classified against a person or family member;
convicted of public indecency or a violation involving a state or federally controlled substance. I am not under current indictment.
Further, I hereby fully release, discharge, and hold harmless the PAL Chapter, participating organizations and all of the fore
going’s employees, officers, directors and coordinators from an all liability, claims, causes of action, costs and expenses which may
be or may at any time hereafter became attributable to my participation in the Mentoring Program.
I understand that the PAL staff reserves the right to terminate a mentor from the program. The program takes place only at the
site designated by the PAL Chapter and does not encourage or approve relationships established between mentor/mentee and
family members beyond the organized and supervised activities of the program. I give permission for program staff to conduct a
criminal background check as part of the screening for entrance into the program. This includes verification of personal employment references as well as criminal checks with authorities. Program staff has a final right of acceptance of an applicant onto the
program and reserves the right to terminate a mentor from the program at any time. I have read the Release Statement and agree
with its contents. I certify that all statements in this application are true and accurate.
Mentor Signature: __________________________________
Please fax or mail this form to PAL Mentoring Coordinator
Email: mentoring@jaxpal.com Fax: (904) 353-9071
Date: ____________________________