Knights of Heroes Foundation / Sponsors And Partners / Mentor Application

Knights of Heroes Mentor Application - Camp Dates: 7 - 14 July 2017

The following information will help us determine if the Knights of Heroes Camp is a good fit for you. Please email if you have any questions: sjstharrold@hotmail.com

First Name

Middle Name

Last Name

Email Address

Phone Number

Please enter your full address:

Street Address

City

State

Zip Code

Date of birth (required in order to conduct a background investigation)

Emergency contact (name and phone number)

Occupation

Marital status

Married

Single

Divorced

Military experience

Formalized training specific to outdoor activities and any certifications you may hold

How did you hear about Knights of Heroes?

What skills do you bring to the team?

Why do you want to be a part of the Knights of Heroes Team?

Please describe your experience working with kids (ages 10-17)

Please describe your spiritual beliefs and what they mean to you

What is your experience with grief? Have you ever lost anyone close to you?

Please list three personal references and phone numbers.

Are you Red Cross CPR certified?

Yes

No

Are you Red Cross First Aid Certified?

Yes

No

Perjury Statement: Any applicant who knowingly or willfully makes false statements of any material fact or thing in the application is guilty of perjury in the second degree as defined in Section 18-8-503, C.R.S. and upon conviction thereof, shall be punished accordingly. Please type your name, date and initials in the box below to signify understanding and acceptance of the aforementioned perjury statement.

Statement of Affirmation in lieu of Background Check Any individual who intentionally enters information on this form that misrepresents, misinforms or misleads, is subject to administrative action and removal: (1) Murder, attempted murder, manslaughter, or arson; (2) Assault, assault with a dangerous weapon, mayhem, malicious disfigurement, or threats to do bodily harm; (3) Burglary; (4) Robbery; (5) Kidnapping; (6) Illegal use or possession of a firearm; (7) Sexual offenses, including indecent exposure; promoting, procuring, completing soliciting, or engaging in prostitution; corrupting minors (sexual relations with children); molesting; voyeurism; committing sex acts in public; incest; rape; sexual assault; sexual battery or sexual abuse; but excluding sodomy between consenting adults; (8) Child abuse or cruelty to ch I have not been convicted, plead no contest, been on probation or been found not guilty by reason of insanity of any of the above listed offenses or their equivalent

True

False

Affirmation I hereby affirm my responsive declaration to each statement on this Affirmation Form and I authorize Knights of Heroes to conduct a criminal background check. I understand that I have the right to obtain a copy of any report from the criminal background check and to challenge the accuracy and completeness of any such report. I also acknowledge that Knights of Heroes may decide to deny or terminate its Provider Agreement with me to provide child care services based on the results of the criminal background check and that I may appeal that decision to the Commission on Human Rights within 30 days of KOH’s written decision. Please type your name, date and initials in the box below to signify understanding and acceptance of the aforementioned perjury statement.

Additional Information