Returning Elders/Mentor Application

Please fill the form. Allow 10-15 minutes to complete the application. Also where you put your name in specific areas it will be considered an ELECTRONIC SIGNATURE.

PROFILE INFORMATION

Street Address, City, State, Zip

Please provide your home number, work number, cell phone number & email. (Please list work, home, and cell in front of each number)

CERTIFICATION
CERTIFICATION: I UNDERSTAND THAT WITHHOLDING INFORMATION REQUESTED ON THIS APPLICATION OR GIVING FALSE INFORMATION MAY MAKE ME INELIGIBLE FOR ACCEPTANCE INTO THE TURNING POINT OF LANSING OR SUBJECT TO DISMISSAL AS AN ELDER. WITH THIS IN MIND, I CERTIFY THAT THE ABOVE STATEMENTS ARE CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I FURTHER UNDERSTAND THAT THIS APPLICATION WILL BE RETURNED IF I HAVE NOT PROVIDED ALL THE INFORMATION NECESSARY TO PROCESS THE APPLICATION.

Privacy Act Statement I understand that all forms and information obtained from me and about me will be held in confidence by The Turning Point of Lansing. Only my application is accessible to me and all other information becomes the property of The Turning Point of Lansing. The Turning Point of Lansing will not release, unless required by law, information from the volunteer file to outside sources without my written approval other than verification that I am a volunteer. I understand that certain information such as Name, Address and Employment may be released to program participants’ parents. In addition, periodically volunteer files are audited for the purpose of program evaluation by the Executive Director of The Turning Point of Lansing and Board of Directors, which will uphold the volunteer’s confidentiality.


***This will serve as an electronic signature

ELDER LIABILITY RELEASE
I understand and agree that I will be the one actually spending time with the mentees in the program, and that I must exercise care in supervising the mentees while we are together. I also understand and agree that I am not a Turning Point of Lansing agent, and the Turning Point of Lansing does not retain any power to control how these activities are conducted except to require these activities to be conducted in the State of Michigan. I, therefore, agree that The Turning Point of Lansing will not be liable for, and I agree to hold The Turning Point of Lansing harmless from any and all liability, causes of action and losses imposed on it in any way relating to or arising out of this mentoring agreement, including, but not limited to, liability for personal injuries, whether the liability, cause of action, or loss is caused by my negligence, or The Turning Point of Lansing negligence or otherwise. I further release The Turning Point of Lansing from any and all liability, claims, demands or actions or causes of action whatsoever arising out of any damage, loss or injury I might incur while participating in any of the activities contemplated by this mentoring agreement, whether such damage, loss, or injury is caused by the negligence of The Turning Point of Lansing, its officers, agents, servants, employees or otherwise.


***This will serve as an electronic signature

AUTHORIZATION OF PERSONAL INFORMATION RELEASED
For the period of one year from the execution of this form I

First & Last

do hereby authorize a release of all said records concerning myself to any duly authorized agent(s) of The Turning Point of Lansing, whether the said records are of a public, private or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of information from any person or agency to include: educational institutions; records maintained by the National Personnel Records Center and the U.S. Veteran’s Administration; County, State or Federal Law Enforcement Agencies; employment and pre-employment records, including background reports, efficiency ratings and complaints or grievances filed by me or against me; psychiatric or psychological and social history/assessment records, wherever they may be maintained; and records pertaining to previous volunteer experience.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability as a The Turning Point of Lansing elder. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release The Turning Point of Lansing from any and all liability which may be incurred as a result of collecting such information.

A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an original signature.

I have read and fully understand the contents of the “Authorization for Release of Personal Information” and certify that all below listed information is correct.

***This will serve as an electronic signature

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