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2018/2019 MAPS (Mentor: Alder & Portland State) Mentor Application

Alder Elementary School has a large population of students who face economic barriers in a diverse multilingual and multicultural area. We hope to
strengthen these students’ aspirations for university achievement at an early age through our MAPS (Mentor: Alder & Portland State) mentoring
program and partnership with Together We Are Greater Than (formerly I Have a Dream Oregon). The MAPS program is hosted by the Student
Community Engagement Center. Transportation is provided by a generous sponsorship from Zipcar. Mentors will be trained during November 2018
and will be matched with their mentee for Winter/Spring 2019 terms.

Priority Deadline to apply for the MAPS program: Friday, November 2, 2018.

The information you provide in this application will be used to assure SCEC is pairing and recruiting the best mentors for our group mentoring
program. Please provide as much information as possible.

For more information or questions, please feel free to email, Alec Martinez at

MAPS Volunteer Mentor Application

Your First and Last Name: [Required]

What is your student ID number (located on your student ID card)? [Required]

What is your email address? [Required]

What is the best method to contact you (ex. text message, email, etc.)? [Required]

What is your cellphone or primary phone number? [Required]

May we use SMS (text messages) to communicate with you? [Required]

Valid input:
- Select only one choice.

[ ] Yes
[ ] No

What year are you in school? [Required]

[ ] Freshman
[ ] Sophomore
[ ] Junior
[ ] Senior
[ ] Graduate

How did you hear about the MAPS program? [Required]

Which times are you available to be at Alder? [Required]

**The actual times of service at Alder will likely be 2-2.5 hours within each day, but since the Alder school schedule is still being finalized, we're hoping our mentors can be
flexible within the four hour time blocks below. Alder is also about half an hour away from PSU -- transportation to and from Alder is provided, or you are free to meet us

[ ] Tuesdays from 9am-1pm

[ ] Wednesdays from 9am-1pm
[ ] Both work for me

We request that you make a commitment as a mentor. In order to be a strong mentor and build a relationship the student needs to be able to rely on
you showing up each week. We ask that no more than 2 days per term missed. Can you make that commitment? [Required]
Valid input:
- Select only one choice.

[ ] Yes
[ ] No

Short Answer

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As a MAPS mentor you will mentor an elementary school student individually and in their classroom. Why are you interested in being a mentor with
the MAPS program? [Required]

Do you have any experience working with youth/kids? If so, please explain below. [Required]

Do you speak any languages other than English? If so, please list languages and proficiency level.

What is your planned area of study? Why? Please feel free to describe your current career goals. [Required]

Do you have any accommodations the mentor program should know about?

We need MAPS drivers!

Do you have a valid driver's license (from any state except CA) and are you willing to drive a Zipcar (university paid) and your fellow mentors to and
from the service site? [Required]
Valid input:
- Select only one choice.

[ ] Yes
[ ] No

Please list the names of two (2) professional references who can attest to your character, skill and dependability along with their phone numbers and
your relation/connection. Some example may be volunteer supervisors, professors or employment supervisor. [Required]

Emergency Contact Information

Please list the name and contact information of at least one person we could contact in case of an emergency. [Required]

Terms and Conditions

I voluntarily agree to participate in PSU Student Community Engagement Center activities,which may include practices, competition, special events,
meetings, and travel.
In consideration for being permitted to participate in the Activity, I hereby agree and warrant that:

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I have read and agree to the following statement: [Required]
Statement and Assumption of Risk: Participation in the Activity can be hazardous to my health. I understand that I have an increased chance of suffering personal injury,
including but not limited to bodily harm, permanent disability, dismemberment, and/or death by participating in the Activity. Injuries that I might incur include, but are not
limited to the following: flesh wounds, muscular-skeletal injuries, cosmetic injuries, permanent disabilities and other injuries including death and or dismemberment. I
understand that traveling to and from the Activity site may present additional risk of serious injury or death, and agree to comply with Activity requirements for the use of
seatbelts by vehicle passengers during travel. I voluntarily undertake the Activity and agree to accept all risk associated with my participation in this Activity. Release of
Liability and Indemnification Statement I understand that there are unavoidable risks involved with participation in this Activity, and I, individually, and on behalf of my heirs,
successors, assigns, and personal representatives, hereby agree to indemnify and hold harmless and release and forever discharge the State of Oregon, the Oregon Board
of Higher Education, the Oregon University System, PSU, and their officers, employees, agents, and representatives, from any and all liability and all claims and causes of
action whatsoever for any damages to or loss of property, personal illness, or injury (including death) caused by, deriving from, or associated with my participation in the
Valid input:
- Select only one choice.

[ ] I Agree

I have read and agree to the following statement: [Required]

Medical Treatment Consent. I fully understand that the Activity may occur in a remote area and that medical services may not be available. In the event of illness or injury to
me, and in the event that medical services can be obtained, and if I am unable to grant permission at the time emergency treatment is required, I hereby authorize PSU by
and through its authorized representative(s) or agent(s), if any, to secure any necessary treatment including the administration of an anesthetic and surgery. I agree to be
the party responsible for all medical expenses that are incurred on my behalf. Statement of Health I certify that I have neither a condition nor circumstance, such as
medication, that would prevent me from participating in this Activity. If I have a question concerning my specific situation, may ask an organizer to clarify the Activity, but
ultimately the decision to participate is mine. Statement of Insurance I am aware that the State of Oregon does not provide medical insurance coverage for participation in
the Activity and therefore take full responsibility for procuring my personal insurance. If I do not have insurance, I accept full, sole and exclusive financial responsibility for
the cost associated with any injury or illness.
Valid input:
- Select only one choice.

[ ] I Agree

I have read and agree to the following statement: [Required]

Choice of Law; Venue Selection. In event of a law suit, I agree that all causes of action will be filed in Multnomah County, Portland, OR and that this Agreement shall be
construed in accordance with the laws of the State of Oregon. Severability If any term or provision of this Agreement shall be held illegal, unenforceable, or in conflict with
any law governing this Agreement the validity of the remaining portions shall not be affected thereby. Final Acknowledgment The forgoing is submitted in consideration of
PSU and the department and./or program noted above allowing my participation in this Activity. I confirm that I am over 18 and I execute this document with full knowledge
of the contents and consequences stated in this release.
Valid input:
- Select only one choice.

[ ] I Agree

All volunteers must pass a criminal background check. If you have any questions or concerns please contact Alec Martinez at

I have read and agree to the following statement: [Required]

• This is an application for and not a commitment or promise to volunteer.
• The provided information is true, and complete to the best of my knowledge.
• Information contained on this application will be verified, if necessary, by the Student Community Engagement Center, by contacting any person or organization that may
have information concerning me.
• SCEC has the ability to terminate any volunteer whose behavior is not in accordance with the expectations of the MAPS program and our community partners at I Have A
Dream Oregon and Alder Elementary School.
Valid input:
- Select only one choice.

[ ] I Agree

Thank you
Thank you for your interest in volunteering with the Mentors: Alder and Portland State program. I really appreciate your interest and enthusiasm for
working with these students. Thank you for your time and I will get back to you as soon as I can regarding next steps.

Make sure to hit continue on this page, and click "Finish" to submit your application on the following screen.

Please feel free to contact Alec Martinez with any questions! Thank you!

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