1615 Illinois Street Bloomington, Illinois 61701

Boys & Girls Club of Bloomington Normal
Mentor Application


Our program time runs from 2:30pm – 6:30pm Monday – Friday; Tutoring/Homework Help are generally Monday – Thursday and Friday is Social Recreation

Do you prefer to work with:
Do you prefer to work with:
Write a brief statement on why you wish to be a mentor in the Mentoring Program at the Boys & Girls Club.
Describe special interests or hobbies that may be helpful in matching you with a mentee

Emergency Contact Information

Mentor Release Statement

I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of the Mentoring Program at the Boys & Girls Club (hereafter known as the "Club"). I understand that the program involves spending a minimum of one hour per week at the Club. I am not allowed to take the youth off the Club grounds. Further, I understand that I will attend a training session, keep in regular contact with my mentee and communicate with staff regularly during this period. I am willing to commit to one semester in the program and then may be asked to renew for another year.

I have not been convicted of (a) any felony of any kind, or any misdemeanor involving (b) harm or threat of harm to another person, (c) controlled substances, (d) acts of a sexual nature, or (e) cruelty to animals. I am not under current indictment.

I, the undersigned, recognize and acknowledge that there are certain risks of physical injury to participants who attend the above event and I agree to assume the full risk of any injuries, damages or loss regardless of severity which I may sustain as a result of participating in any and all activities connected with or associated with such an event.

I, the undersigned, do hereby grant permission to Boys & Girls Clubs of Bloomington-Normal to use my image. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of myself for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images.

I, the undersigned, authorize Boys & Girls Clubs of Bloomington-Normal to run a local, state and federal background check.

I agree to waive and relinquish all claims I may have against the Boys & Girls Clubs of Bloomington-Normal (BGCBN) and its employees as a result of participation in the event. I do hereby give full release and discharge BGCBN and its employees from any and all claims from injuries, damages, or losses which I may have or which may accrue to me arising out of it, connected with, or in any way associated with the activities of BGCBN.

I further agree to indemnify and hold harmless and defend BGCBN and its employees from any and all claims resulting from injuries, damages and losses sustained by me arising out of, connected with, or in any way associated with the BGCBN event.

In the event of an emergency, I authorize BGCBN to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for my immediate care and agree that I will be responsible for payment of any and all medical services rendered.

I further understand that I must follow all safety rules and instructions given by the employees of BGCBN and failure to do so may result in suspension from BGCBN. I have read fully and understand the above waiver and release all claims, agree to follow the rules and give permission to secure treatment.

I understand that the Club staff reserves the right to terminate a mentor from the program. The program takes place only at the Club and does not encourage or approve of relationships established between mentor/mentee and family members beyond the organized and supervised activities of the program. I give permission for program staff to conduct a criminal background check as part of the screening for entrance into the program. This includes verification of personal and employment references as well as a criminal check with the authorities. Program staff has final right of acceptance of applicant into the program and reserves the right to terminate a mentor from the program at any time. I have read this Release Statement and agree to the contents. I certify that all statements in this application are true and accurate.

Mentor Signature