Experience is not what happens to a man. It is what a man does with what happens to him

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  • Services Provided

    Mental/Emotional Health




    Gender Specific

    After School Care


  • Behavioral Outcome

    School Attendance





    Gang Involvement



    Not Attending

    Follow rules

    Known gang members

    Poor Attendance

    Does not follow rules

    Intent to join

    Good Attendance

    Required intervention

    No longer participating

    Perfect Attendance


    Never been a member

    Academic Performance

    Chemical Dependency

    Delinquent Behavior

    Failing two or more subjects



    Failing one subject


    Referred to court




    Honor Roll

    Has never used

    Repeat offender

    Attachment H
    From US Department of Justice, Office of Juvenile Justice and Delinquency Prevention
    These forms are based on those developed by the Missing and Exploited Children Comprehensive Action Program and the National School Safety Center under a grant form the Office of Juvenile Justice and Delinquency Prevention, Office of Justice programs, U.S. Department of Justice (see Hiring the Right People, Guidelines for the Selection and Screening of Youth-Service Professionals and Volunteers, 1994). They are included as a starting point for the development of forms by states; agencies; associations; organizations; coalitions; or individuals serving children, the elderly, and individuals with disabilities in need of support.

    Community Mentoring for Adolescent Development

    Funded by the Texas Commission on Alcohol and Drug Abuse
    Authorization to Release Information
    Applicant’s name: _____________________________________________________________

    Applicant’s address: _____________________________________________________

    Applicant’s social security number: ________________________________________________

    Agency contact person: _________________________________________________________

    Authorization expiration date: _____________________________________________________
    I, the undersigned, authorize and consent to any person, firm, organization, or corporation provided a copy (including photocopy or facsimile copy) of this Authorization to Release Information by the above-stated agency to release and disclose to such agency any and all information or records requested regarding me, including, but not necessarily limited to, my employment records, volunteer experience, military records, criminal information records (if any), and background. I have authorized this information to be released, either in writing or via telephone, in connection with my application for employment or to be a volunteer at the agency.
    Any person, firm, organization, or corporation providing information or records in accordance with this authorization is released from any and all claims or liability for compliance. Such information will be held in confidence in accordance with agency guidelines.
    This authorization expires on the date stated above.
    ____________________________ ___________________

    Signature Date

    ____________________________ ___________________

    Witness to Signature Date

    Community Mentoring for Adolescent Development

    Funded by the Texas Commission on Alcohol and Drug Abuse

    Application Disclosure Affidavit

    (Please read carefully.)

    Our agency screens prospective employees and volunteers to evaluate whether an applicant poses a risk of harm to the children and youth it serves. Information obtained is not an automatic bar to employment or volunteer work, but is considered in view of all relevant circumstances. This disclosure is required from applicants in order to be considered for positions. Any falsification, misrepresentation, or incompleteness in this disclosure alone is grounds for disqualification or termination.

    APPLICANT: __________________________________________________________

    Please print complete name and social security number

    The undersigned applicant affirms that I HAVE NOT at ANY TIME (whether as an adult or juvenile):
    YES NO (Initial answer under “yes” or “no” and provide brief explanation for a “yes” answer below.)
    ____ ____ Been convicted of _________.

    ____ ____ Pleaded guilty to_______ (whether or not resulting in conviction).

    ____ ____ Admitted________.

    ____ ____ Had any judgment or order rendered against me (whether by default

    or otherwise).

    ____ ____ Entered into any settlement or action or claim of ________.

    ____ ____ Had any license, certificate, or employment suspended, revoked,
    terminated, or adversely affected because of __________.

    ____ ____ Been diagnosed as having or been treated for any mental or

    emotional condition arising from __________.

    ____ ____ Resigned under threat of termination of employment or volunteer

    work for _________.
    Any allegation, conduct, matter, or thing (irrespective of the formal name thereof) constituting or involving (whether under criminal or civil law of any jurisdiction):
    YES NO (Initial answer under “yes” or “no” and provide brief explanation for a “yes” answer below.
    ____ ____ Any felony

    ____ ____ Rape or other sexual assault

    Application Disclosure Affidavit, Continued
    ____ ____ Drug or alcohol related offenses

    ____ ____ Abuse of a minor or child, whether physical or sexual

    ____ ____ Incest

    ____ ____ Kidnapping, false imprisonment, or abduction

    ____ ____ Sexual harassment

    ____ ____ Sexual exploitation of a minor

    ____ ____ Sexual conduct with a minor

    ____ ____ Annoying/molesting a child

    ____ ____ Lewdness and/or indecent exposure

    ____ ____ Lewd and lascivious behavior

    ____ ____ Obscene literature

    ____ ____ Assault, battery, or other offense involving a minor

    ____ ____ Endangerment of a child

    ____ ____ Any misdemeanor or other offense classification involving a minor

    or to which a minor was a witness

    ____ ____ Unfitness as a parent or custodian

    ____ ____ Removing children from a state or concealing children in violation
    of a law or court order

    ____ ____ Restrictions or limitations on contact or visitation with children or


    ____ ____ Similar or related conduct or incidents

    ____ ____ Accusation of any of the above
    (If you answered “yes” to any of the above, please explain. If none, write “none.”)
    Description Dates


    The above statements are true and complete to the best of my knowledge.
    Date: ___________________ ______________________________

    Applicant’s signature

    Date: ___________________ ______________________________

    Witness to signature

    Community Mentoring for Adolescent Development

    Funded by the Texas Commission on Alcohol and Drug Abuse

    Request for Information

    TO: _____________________________________________________________________________
    APPLICANT: ____________________________________________________________________
    Name: _______________________ Social Security Number: ________________
    Date of Employment: ____________ Immediate Supervisor: _________________
    Our agency, (insert name), is requesting information regarding the above-mentioned applicant who is seeking a position. This agency serves children and youth, and, accordingly, undertakes background investigations to determine whether the individual poses a risk of harm to those who would be served.
    We are interested in receiving any information or records that would reflect on the applicant’s fitness to work with children and youth. Please complete the attached Employer Disclosure Affidavit and return it to our agency at your earliest convenience. Although any information you wish to provide is welcome, we are especially interested in any conduct, matter, or incident that involves an established or reasonable basis for suspecting physical, psychological, or sexual misconduct with respect to children or youth.
    You may receive a separate written or telephone request from our agency for an employment reference regarding the applicant. Please respond to each request independently.
    With this request is an authorization executed by the applicant. This releases you from any liability for your reply, either in writing or via telephone.
    Thank you for your assistance.
    Very truly yours,


    Failure by your agency or organization to provide information requested may result in automatic disqualification of the applicant.

    Baylor University’s Community Mentoring for Adolescent Development   

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