09.63 Highlands Mentor Application from School Board of Highlands County

The School Board of Highlands County
426 School Street, Sebring, Florida 33870 (863) 471-5791
www.highlands.k12.fl.us

Minimum Age Requirement - 18 years of age and Human Resources approval. Students enrolled in any Highlands County school are not eligible to mentor other students regardless of age.
Human Resources requires a minimum of twenty-one (21) business days to process applications. Applicants with a criminal history will require additional processing time; therefore, should plan accordingly.

This is a:		I am a:

I would like to mentor at:

PERSONAL INFO

All personal information is required to complete criminal history background screening and remains confidential. All mentor applicants will undergo a Level 2 background screening. Background clearance fees for ongoing mentor services will be borne by the District. Background clearances are valid for five (5) years from date of clearance.

First Name:
Middle Name:
Last Name:
Suffix:

Social Security #:		DOB:		Gender:

Race/Ethnicity:

Address:
City:

State:		Zip:

Email Address:

Please be advised that if you have an e-mail address with embarqmail or century link, our e-mails from the School Board of Highlands County are not being delivered to your inbox. Please add mailbot@applitrack.com to your address book so our e-mails are able to be delivered. We communicate via e-mail so it is imperative that you do this, in order for our volunteer application processing to be initiated.

Phone #:		Ext:		Phone Type:

ADDITIONAL INFO

Employer:
Employer Phone:

SBHC ENROLLED STUDENTS

Please list children you currently have enrolled within the SBHC system:

First & Last Name:
Date of Birth:
School:
Teacher:
First & Last Name:
Date of Birth:
School:
Teacher:
First & Last Name:
Date of Birth:
School:
Teacher:
First & Last Name:
Date of Birth:
School:
Teacher:

CRIMINAL HISTORY & DISCLOSURES

Applicants currently serving probation will be denied

To become a School Board of Highlands County mentor, a criminal background screening will be conducted. A prior record may or may not result in your disqualification for mentoring; however, failure to disclose your record on this application will automatically result in application denial. Applicant will not be reconsidered for one year.

In Florida, the entire arrest record is revealed to school districts by the Florida Department of Law Enforcement and/or FBI, including juvenile, sealed or expunged records and military court proceedings. Factors such as age at the time of the offense, type of offense, remoteness of the offense will be considered when determining the suitablility for mentoring.

FLORIDA LAW requires that you MUST DISCLOSE this information even if you have been told differently by a lawyer, judge or other third party or law enforcement individuals. All criminal histories must be provided regardless of the number of years since the arrest.

You must answer all questions for your application to be considered complete. Incomplete applications will not be processed.

YesNo	Have you ever been convicted, plead guilty, or plead nolo contendere to a criminal offense, other than a minor traffic violation (includes, but not limited to a felony, gross misdemeanor, misdemeanor, DUI)?
YesNo	Have you ever been incarcerated, received probation, deferred judgement, pre-trial intervention/diversion, nolle prosequi or adjudication withheld?
YesNo	Are you currently serving probation?
YesNo	Are you currently under investigation, or have you ever been named in an indictment, accusation, or special presentment of any offense other than a minor traffic violation?
YesNo	Have you ever had any arrest record sealed or expunged in which you were convicted, found guilty, had adjudication withheld, entered a pre-trial diversion program, or pled guilty or nolo contender (no contest) to a criminal offense other than a minor traffic violation (DUI is not a minor traffic violation)?
YesNo	Have you ever been named, by a state agency, responsible for child welfare as a perpetrator in an indicated report of child abuse, abandonment, or neglect?
YesNo	Have you ever had a report of child abuse or sexual activities involving a K-12 student or minor filed against you with a school district, a state or federal agency, a policy agency, or in court?
YesNo	Does your name appear on a sex offender database in any state or country?

If yes was indicated for any of the above questions, you must provide thorough and complete details below. Further information, including disposition (final outcome), for each record listed may be requested.

(1) City & State of Arrest:		Date of Arrest:		Age:

Nature of Charges		Disposition

(2) City & State of Arrest:		Date of Arrest:		Age:

Nature of Charges		Disposition

(3) City & State of Arrest:		Date of Arrest:		Age:

Nature of Charges		Disposition

(4) City & State of Arrest:		Date of Arrest:		Age:

Nature of Charges		Disposition

Acknowledgements & Agreements

Self-Reporting of Criminal Offenses (adopted from SBHC policy as per f.s. 1012.465) All arrests of all mentors shall be self-reported within 48 hours to the School Board of Highlands County Human Resources Department. Such notice shall not be considered an admission of guilt nor shall such notice be admissible for any purpose in any proceeding, civil or criminal, administrative or judicial. A phone message can be left 24 hours a day at (863) 471-5733. The mentor must provide a written follow-up statement within five (5) business days of leaving the message. Failure to self-report may result in inactive status.
Background Investigation Authorization I authorize the School Board of Highlands County to conduct an investigation of mentor applicant pursuant to district policy to determine whether applicant has been convicted of any criminal or drug offenses as set forth in such a statute. District policy also stipulates that the school district must perform an inquiry on the Statewide Sex Offender Database. Applicant may not be approved unless such investigations have been performed.
Student Confidentiality Statement Florida Statute 1002.22 protects the rights of privacy with regard to student information and records, to include academic performance, grades, test scores, attendance and discipline records, health data, family background data, ratings and observations from teachers and guidance counselors. This information is confidential and is not to be discussed with anyone other than designated school personnel. Failure to respect the privacy rights of students has legal consequences.
Application Validity Period Mentor approval is a privilege. Approved mentors are considered a role model for students. Mentors are expected to operate within the boundaries of school board policy and serve at the discretion of the local school. Approved mentors remain active for five (5) years from the time of the application is approved. It is the responsibility of the mentor to submit a renewal application one (1) month prior to the expiring active status. Active status may be revoked, at anytime within the five (5) year validity period, at the discretion of the School Board of Highlands County.
Statement of Understanding I understand I am offering my services to the School Board of Highlands County without compensation. I certify that all information provided on this application is true and complete, and I understand any misrepresentation, omission or incorrect statement of facts called for in this application is cause for immediate deactivation as a mentor. I agree to abide by all school board rules, regulations and policies, either published or in effect by usage including all rules, regulations and laws governing the State of Florida. I also understand that clearance to mentor for the School Board of Highlands County does not equate to clearance for employment.

Digital Signature	Signing Signature is required

Type your full legal name. A digital signature is as legally binding as a hand written signature.

School Board of Highlands County - 09.63 Highlands Mentor Application