Reading Partner Program Application

Contact Information Salutation First Name * Middle Name * Last Name * Home Address * City * State * Postal Code * Home Phone * Work Phone Mobile Phone Best Time to Contact You Email Address*

Background Information Have you ever been accused, charged or convicted of a crime? If yes, explain How long have you lived in the Twin Ports Area? How did you hear about the Reading Partner Program?

Three Preferred Reading Times

Time Time Time

Day Day Day

Personal References

Please list the names and addresses of three (3) persons who can vouch for your reputation and character and who have known you for at least two (2) years.
When listing personal references, please use the names of people who have seen you work with children.
Please notify your references and encourage them to return their reference form as soon as possible after receiving them.

Reference 1 Name * Address * City * State * Postal Code * Home Phone * Work Phone Email Address

Reference 2 Name * Address * City * State * Postal Code * Home Phone * Work Phone Email Address

Family Reference Name * Address * City * State * Postal Code * Home Phone * Work Phone Email Address

The undersigned acknowledges and agrees that

He/she is not obligated, if called upon, to perform the volunteer servicesherin applied for and that the agency is not obligated to assign, or actively seek to assign him/her a child and
I also agree to contact volunteer staff if any critical information (ie: License revocation, DUI's, criminal charges and/or convictions) occur after I have become part of the Reading Partner Program.

Signature * Date *

Men As Peacemakers

Fostering and developing peacemakers through, modeling, mentoring, storytelling and dialogue.

Reading Partner Program Application