C.A.R.E.S Mentor Application

Please list three references who have known you for more than one year. Input complete names, addresses, telephone numbers, and relationship for three people you authorize us to contact who would evaluate your qualifications as a volunteer. Do not include more than one family member.

As a volunteer for the CARES (Children Are Reaching Excellence with Support) Mentoring Program, I agree to the following:

• • To attend a training session before beginning
• • To be on time for scheduled meetings
• • To notify the school office if I am unable to keep my weekly meeting
• • To engage in the relationship with an open mind
• • To accept assistance from my mentee’s teacher
• • To keep discussions with my mentee confidential
• • To ask for assistance when I need help with my mentee
• • To notify the agency of changes in my employment, address, and phone number

Delta Health Alliance (“the Company”) may obtain information about you from a consumer reporting agency for employment or volunteer purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends or associates. These reports may contain information regarding your criminal history, credit history, motor vehicle records (“driving records”), verification of your education or employment history or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment or volunteerism with the Company is an investigation into your education, criminal and/or employment history conducted by Scott-Roberts and Associates, LLC, 2290 10 Ave. N., Lake Worth, Florida 3346l, (888)605-4265, www.scottrobertsassociates.com , or another outside organization. You should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. One application per person. By signing this document you agree you have read and understand this disclosure.

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or ‘”investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, insurance company, or other party to furnish any and all background information requested by Scott-Roberts and Associates, LLC, 2290 10 Ave. N., Lake Worth, Florida 33461, (888)605-4265, www.scottrobertsassociates.com, another outside organization acting on behalf of Delta Health Alliance, and/or Delta Health Alliance itself. I agree that a facsimile (“fax”) or electronic or photographic copy of this Authorization shall be as valid as the original.