Knights of Heroes Foundation


New Mentor Application
First Name *
Middle Name
Last Name *
Gender *
Birth Date *	// (mm/dd/yyyy)
Email *
Cell Phone *
Address 1 *
City *
State *
Zip *
Occupation
Emergency Contact Name and Phone Number *
Marital Status *
Military Experience
What skills do you bring to the team? *
Why do you want to be a part of the Knights of Heroes team? *
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 describe your experience working with kids (ages 0-17) *
Personal References
Please list three personal references with phone numbers *
Qualifications
Are you Red Cross CPR certified? *	Yes No
Are you Red Cross First Aid Certified? *	Yes No
Formalized training specific to outdoor activities and any certification you may hold
Perjury Statement
Any applicant who knowingly or willingly 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 children
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 *
Affirmation
I hereby affirm my responsive declaration to each statement on this Affirmation Form and I authorize Knights of Heroes to conduct 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.
Again, please type your name, date, and initials in the box below to signify understanding and acceptance of the aforementioned perjury statement *
Additional Information
How did you hear about KOH *
Additional Information

Neon CRM by Neon One

Timeout Warning

New Mentor Application

Personal References

Qualifications

Perjury Statement

Statement of Affirmation in Lieu of Background Check

Affirmation

Additional Information