MENTOR 2021-2022 PAPERWORK - Healthy Mothers, Healthy Babies
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2021-2022 MENTOR PAPERWORK
Caps & Cribs 2021-2022 Mentor Agreement
All the information you are told about your student is confidential and sharing that information with others is prohibited. However,
you are required to report certain things. Do promise a student that you will keep confidential information secret. Tell the student
that she is free to share confidential information with you but that you are required to report certain things. It is critical, not only for
the welfare of the student, but also to protect yourself that you adhere to these exceptions.
These procedures are designed to protect the student from harm and to prevent even the appearance of impropriety on the part of
Healthy Mothers, Healthy Babies and its participating mentors, volunteers, and students. One accusation, at the very least, could
seriously damage the reputation of all participating.
Please check and acknowledge that you understand the following statements:
o If a student confides that he or she is the victim of sexual, emotional or physical abuse, you MUST immediately call DCF
(Department of Children & Families). After you’ve called DCF, you must notify Healthy Mothers, Healthy Babies immediately.
Next, you must complete the Healthy Mothers, Healthy Babies incident form and email it to the program coordinator.
Remember this information is extremely personal and capable of damaging lives, so DO NOT share it with anyone except the
appropriate authorities.
o If a student tells you of his or her involvement in any illegal activity you MUST tell Healthy Mothers, Healthy Babies
immediately. Again, note when this information was reported and to whom it was given.
By choosing to participate in the Healthy Mothers, Healthy Babies Caps & Cribs Teen Mom Mentoring program
I agree to:
o Follow all rules and guideline outlined by the program coordinator, program policies, and this agreement or I may be
removed the program.
o Assist my mentee with submitting all curriculum activities to the program coordinator on time.
o Make the commitment to be matched with mentee until she graduates high school.
o Attend group mentor activities as provided if I’m available.
o Allow Healthy Mothers, Healthy Babies to use my photo in marketing materials.
o Keep any information that my mentee tells me confidential except as may cause her or others harm.
o Refrain from babysitting my mentee’s child(ren).
o Refrain from transporting my mentee in my vehicle unless I’m authorized to do so.
o Notify the program coordinator if I have any changes to my address, phone number, email address, or employment status
and notify my mentee if my phone number changes.
o Upon match closure that future contact with my mentee is beyond the scope of the Healthy Mothers, Healthy Babies Caps &
Cribs Teen Mom Mentoring program may happen only by mutual consensus of the mentor and the mentee.
o Follow all current COVID CDC guidelines and guidelines communicated by Healthy Mothers, Healthy Babies.
o Be on time for scheduled meetings or contact mentee ASAP or at least 24 hours beforehand if I’m unable to make a
meeting.
o Make at least one contact weekly with total contact adding up to at least one hour between in-person, texts, emails, and
phone calls.
o Notify the program coordinator if 7 consecutive days go by with no mentee contact.
o Notify the program coordinator of any difficulties or areas of concern that may arise in your relationship.
o Notify the program coordinator if personal difficulties arise causing me to longer have the ability to meet program
requiements i.e. illnesses, employment change, etc.)
o Make myself available for a 15-minute monthly supervision call from the program coordinator.
o Enter portal entries before the last day of the month.
o Return texts, emails, and voicemails from the program coordinator within 24 hours.
o Return texts, emails, and voicemails from my mentee within 24 hours.
o Notify the program coordinator ASAP if I’m no longer interest in being matched with my mentee.
By signing this document I hereby agree to all of the above and release Healthy Mothers, Healthy Babies Coalition of Palm Beach
County, Inc. and its agents, officials, representatives or assigned agencies, including officers, employees or related personnel, both
individually and collectively, from any and all liability for damages of whatever kind which may at any time result to me because of
compliance of this authorization.
Sign____________________________________________________________ Date_________________________________________
Print Name______________________________________________________MENTOR BACKGROUND SCREENING AUTHORIZATION FORM: PART 1
_______ I understand Healthy Mothers, Healthy Babies Coalition of Palm Beach County does not
discriminate based on gender, race, creed, age, sexual orientation, national origin, religion, marital status, or
disability.
_______ I understand that as part of the screening process, it will be necessary for
Healthy Mothers, Healthy Babies Coalition of Palm Beach County to investigate my background by means of
character references, referrals from other youth organizations, criminal record, child abuse registry check, driver
license check, home assessment and other records where required by local, state, or federal law for volunteers
working with youth. I also understand that it may be necessary to obtain information concerning my psychological,
psychiatric, or medical history and/or any other information, which may have a bearing on my ability to serve as a
mentor.
_______ I understand that all information is confidential and for agency use only.
_______ I acknowledge and agree that I am not obligated, if called upon, to perform the volunteer
services herein applied for, and that the agency is not obligated to assign or actively seek to assign me a mentee.
As part of the agency’s matching process, professional agency personnel will elicit additional personal information
from me.
_______ I acknowledge that this is a volunteer project and there will be no compensation for my time.
_______ I acknowledge that my commitment to the program is one hour per week and to strive to stay
connected to my mentee for one year.
_______ I understand that in order to establish an appropriate match, Healthy Mothers, Healthy
Babies Coalition of Palm Beach County shares relevant information about the teen with the mentor and about the
mentor with the child and parent/guardian. New information that arises subsequent to the match may be shared
with match participants if deemed necessary by the professional staff. I agree to keep information regarding any
potential mentee confidential and to not discuss it with anyone other than the professional staff of Healthy Mothers,
Healthy Babies.
_______ I agree to allow the agency use of pictures for media/ recruitment purposes.
I, ________________________________________ , authorize Healthy Mothers, Healthy Babies Coalition of Palm Beach
County and its designated agents and representatives to conduct a comprehensive review of my background in connection
with my application to be a mentor. I hereby release Healthy Mothers, Healthy Babies Coalition of Palm Beach County and
its agents, officials, representatives or assigned agencies, including officers, employees or related personnel, both
individually and collectively, from any and all liability for damages of whatever kind which may at any time result to me
because of compliance with this authorization.
Signature _________________________________ Print Name______________________________
Date _____________________________MENTOR BACKGROUND SCREENING AUTHORIZATION FORM: PART 2 Healthy Mothers, Healthy Babies Coalition of Palm Beach County mentors work with youth, therefore, we are required to screen our volunteers. Please respond to the following questions and sign the authorization below. The Level 2 background check (including fingerprinting) are paid for by Healthy Mothers, Healthy Babies. Name: _________________________________________ Date of Birth: ____________________ Gender: Male Female Have you ever been convicted of, pled guilty or entered a plea of no contest to a felony or first-degree misdemeanor? Yes No Have you ever had the adjudication of guilt withheld for a crime which is a felony or first-degree misdemeanor? Yes No If yes to either, please supply details (date, where, charge, disposition). __________________________________________________________________________________________________ ________________________________________________________________________ If you have changed your name, please provide us with your previous name(s): Current Address: City, State, Zip: Please provide us with your previous residential address if less than one (1) year at your current residence: Signature _________________________________ Print Name______________________________ Date _____________________________
Video & Photo Release I consent that any and all videos and photographs taken of me by a representative for Healthy Mothers/Healthy Babies of Palm Beach County, Inc., or my name, may be used for news articles and promotional materials that will benefit the agency and increase its visibility in a favorable way. Healthy Mothers/Healthy Babies may use these photos without restriction, and I hold them harmless from any liability in this connection. No other personal information will be printed without consent. I am aware that should a special event involve the media, Healthy Mothers/Healthy Babies may not be able to control what information the media will gather or what questions may be asked or put in print. Name of Person Being Photographed Address, City/State and Zip Code Telephone Number Signature of Consent Date
Caps & Cribs Teen Mom Mentoring
Program Transportation Policy & Volunteer Authorization
It is the policy of Healthy Mothers, Healthy Babies’ Caps & Cribs Teen Mom Mentoring Program to allow
mentors to transport mentees in their own private vehicles for the purpose of the program. The Program
Coordinator must ensure that all mentors who will be driving their mentees meet the following criteria prior to
transporting the mentee:
• All mentors must own a car or have access to reliable insured transportation.
• All mentors must possess a valid driver’s license and present proof of auto insurance ($100K$300K
stacked coverage is required); a record of insurance will be maintained in the mentor’s file and will be
updated on an annual basis.
• All mentors must undergo a driving check and have a clean driving record for the last three years. In
the event that the mentor does not have a clean record, transportation of the mentee will not be
allowed.
• Healthy Mothers, Healthy Babies requires that mentors obey all traffic laws, and use seat belts and
headlights at all times. Children under the age of 15 are mandated to sit in the back seat. Children of
mentees under the age of 8 must be seated in the rear and secured in an appropriate car seat based
on age.
• Mentors must also avoid taking medications or using any other substances that might impair their
ability to drive. If an accident occurs while the mentor is engaged in mentoring, it should be reported
to the Program Coordinator immediately.
• The mentor must carry a copy of the mentee’s health insurance information in the transporting
automobile at all times in case of emergency.
If any of the above policy is not adhered to, the mentor will not be allowed to transport the mentee in
a private automobile.
Motor Vehicle Report Authorization
In compliance with public law 91-508 (the Fair Credit Reporting Act), as mended by Public Law 104-
108 and applicable state law, this notice is to inform you that the Motor Vehicle Report may be
obtained in connection with your mentor volunteer application. If obtained, this consumer report may
be used in making decisions concerning your application for volunteering and/or volunteer status with
Healthy Mothers, Healthy Babies Palm Beach County, Inc. because your time in the Caps & Cribs
program may involve transporting your mentee by personal vehicle.
In addition to the Motor Vehicle Report, HMHB will require a current copy of your vehicle insurance card and
declaration page. Furthermore, HMHB requires that volunteer vehicle coverage be no less than $100K/$300K
stacked.
/Users/jensilliman/Downloads/Mentor Transportation.doc Rev. 04/11/2016Policies & Procedures
In addition to the Motor Vehicle Report, HMHB will require a current copy of your vehicle insurance
card and declaration page. Furthermore, HMHB requires that volunteer vehicle coverage be no less
than $100K/$300K stacked.
I WILL NOT TRANSPORT MY MENTEE OR HER CHILD IN MY PRIVATE VEHICLE.
_________________________________ ______________________________
Signature of Volunteer Applicant Print Name of Volunteer Applicant
_________________
Date
Request for Information from Driver License Records
Driver License Number:
____ ____ ____ ____ - ____ ____ ____ - ____ ____ - ____ ____ ____
_______________________________________________________________________
Exact name on Driver’s License
_________________________________________
Date of Birth
_________________________________________
State
/Users/jensilliman/Downloads/Mentor Transportation.doc Rev. 10/11/2016You can also read
