Mentor Application

I hereby authorize the Challenge Academy, along with law enforcement departments, to conduct whatever background check on me that may be deemed appropriate. I understand that this information is necessary to assist in determining my qualifications and suitability for a mentor position that I am applying for.

I fully understand that the information collected may be of a sensitive, confidential, and privileged nature, and may reflect upon my suitability. I hereby release the Challenge Academy and its agents from damage that may result from the exchange of requested information between law enforcement departments and the Challenge Academy.

I further authorize the Challenge Academy to release information, as deemed necessary, for the purpose of developing longitudinal and statistical studies and reports.

The information provided in this application is true and accurate to the best of my knowledge.

• Serves as a role model, friend and advocate to the Cadet.
• Reports to the assigned Counselor and/or Mentor Coordinator.
• Returns completed screening material promptly.
• Commits to consistent contact with a Cadet while he/she is participating in the Challenge Academy.
• Observes all program policies and guidelines for mentors.
• Attends mentor training to learn how to relate effectively to Cadets.
• Participates in scheduled trainings and activities such as On/Off-site, and PRAP Review.
• Agrees to being contacted on a monthly basis by the Challenge Academy’s assigned Counselor, for the purpose of
discussing the Cadet’s progress.
• Discusses violations of policies by the Cadet with the Counselor and/or Mentor Coordinator.
• Communicates monthly by mail, e-mail, or phone with their Cadet’s assigned Counselor. Promptly informs the Counselor
and/or Mentor Coordinator of problems or needs in the Cadet’s life or their relationship.
• Makes consistent contact with the Cadet by phone, mail, e-mail, or in person.
• Maintains a minimum of 4 units of contact with Cadet monthly, as required.
• Submits a monthly report to the Challenge Academy when scheduled during weeks 14-22 of the Residential phase and
months 1-12 of the Post-Residential Phase.
• Monitor the Cadet’s Post-Residential Action Plan. Discusses with the Cadet his/her progress in executing the plan.
• Reports any changes of the Plan to the Cadet’s Assigned Counselor.
• Refers the Cadet to community resources as needed and helps the Cadet obtain those resources.
• Completes a community service project in your home community with the Cadet once per quarter during the Post-
Residential phase of the program.
• Shares informal activities with his/her Cadet. The mentor and Cadet will jointly select and schedule the activities.
• Completes an Exit Interview by phone, mail, or e-mail at the completion of the 17-month program.

I understand and agree that I will be the one actually spending time with my Cadet and that I must exercise care in supervising him/her while we are together. I also understand that I am not a Challenge Academy employee, agent, and that I am responsible for choosing and conducting all activities with my Cadet and that the Challenge Academy does not retain any power to control how these activities are conducted except to require these activities to be conducted in the State of Wisconsin.

I therefore agree that the Challenge Academy, the National Guard Bureau, the State of Wisconsin, the Wisconsin National Guard, and their respective officers, officials, agents and employees (Released Parties) will not be liable for, and I agree to indemnify and hold harmless the Released Parties from any and all liability, causes of action, and losses imposed on them in
any way relating to or arising out of this mentoring agreement, including, but not limited to, liability for personal injuries, whether the liability, cause of action, or loss is caused by my action or inaction or the actions of inactions of the Release Parties.

I further release the Released Parties from any and all liability, claims, demands, or causes of action, whatsoever, arising out of any damage, loss, or injury I might sustain while participating in any activities pursuant to this mentoring agreement, whether such damage, loss, or injury is caused by the actions or inactions of the Release Parties.

My signature below certifies that I have read, agree to and understand the material above.

I authorize the Wisconsin National Guard Challenge Academy (Academy) to release my name, address, and telephone numbers to an institution or individual, whether public or private, for the purpose of advocating, supporting, and
furthering the mission of the Academy.

I further authorize the Academy to release said information as deemed necessary for the purpose of forming a parent support group, parent association, membership on a foundation to benefit the Academy, letter writing campaigns and class
reunions. This release shall remain in effect until revoked in writing by the undersigned individual(s).

My signature below certifies that I have read, agree to and understand the material above.

Confidentiality is the preservation of privileged information concerning the client, which is disclosed in a professional working relationship. Part of what you learn is necessary to provide services to the applicant or client; other information is shared within the development of a helping trusting relationship. Therefore, most information gained on an individual and
family is classified as confidential.

Before you begin your assignment as a mentor you should be aware of the laws and penalties of breaching confidentiality. Giving information to unauthorized personnel could be interpreted as not within the scope of your duties. In this case Challenge Academy could refuse to support you in the event of legal action. Violation of the Wisconsin Revised Statues regarding confidentiality of records is punishable upon conviction by imprisonment in county jail for not more than sixty (60) days, or fines of $1000, or both. My duties as a mentor are to abide by the laws and policies regarding the preservation of confidential information.

My signature below certifies that I have read and understand the material above.