Program Application

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MENTOR's SafetyNET Program

These companies are graciously underwriting the operations of SafetyNET. All personal data
for SafetyNET programs and volunteers is held in the strictest confidence by MENTOR.

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SafetyNET Manual and Forms

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Application to Join the SafetyNET Pilot Program

Please fill out the form below to apply to become an authorized user of MENTOR’s SafetyNET Pilot program. If approved, your organization will be authorized to obtain FBI fingerprint background checks on prospective volunteers.

Before you apply, please carefully read the Fact Sheet and the SafetyNET Manual to become familiar with how the pilot works and what it means for your organization. This manual explains everything you need to know about the pilot program, including the fingerprint process, cost, turnaround time, and other key details. If you have any questions, please contact MENTOR.

This application can only be completed by the person in your organization responsible for screening volunteers and accessing background check results. You will also be required to certify several things in this application, so read carefully.

Please complete every field. For questions, please contact MENTOR.

Program Information:

Program Name:
Address:
Address:
City:
State:
Zip:

Type of Program:	Community-based
	School-based
	Work-based
	Faith-based
	E-mentoring
	Other

Are you an independent 501(c)3?	Yes
	No

If yes, please provide your Employer Identification Number (EIN):
EIN:
What is an EIN?

If no, what organization are you affiliated with?
Name:
Address:
Contact Name:

Mentoring is defined as: Either 1 Adult to 1 youth or 1 Adult to no more than four youth Long-Term (at least three consecutive months) Frequent Contact (at least four hours per month) Location can be site-based or community-based
Does your program meet the definition of mentoring?	Yes No

Are you currently listed in MENTOR’s Volunteer Referral Database?	Yes No
If not currently listed, check here to receive information on how to get listed:

Please estimate how many background checks you will perform on volunteers over the next 12 months:

Your Information: Note: You must be the person responsible for screening volunteers and accessing background check results

First Name:
Last Name:
Title:
Phone:
Fax:
E-mail:
Confirm E-mail:

Certifications:

	I certify that my mentoring organization ultimately bears full responsibility for the screening of mentors and the placement of mentors in the most suitable roles. MENTOR is not in any way liable for any screening decisions that anyone in my organization makes about a volunteer's status based on information obtained in the SafetyNET pilot program.

	I understand that, based upon criminal history record information held by the FBI, a determination will be rendered exclusively by NCMEC as to a volunteer's fitness to serve in a mentor capacity. Neither NCMEC nor MENTOR are liable for any screening decisions that a mentoring organization makes about a volunteer's status based on information obtained in the SafetyNET pilot.

	By applying to participate in the pilot program, I certify that I, and my mentoring organization, understand and accept the terms contained within the SafetyNET Manual, including any disclaimers of liability on the part of MENTOR.