A BETTER OREGON…ONE YOUTH AT A TIME
OREGON NATIONAL GUARD YOUTH CHALLENGE PROGRAM RULES AND REGULATIONS
YOUTH CHALLENGE APPRECIATES YOUR INTEREST
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
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YOUTH CHALLENGE PROGRAM RULES AND REGULATIONS (basic description)
THIS IS THE BASIC PROGRAM DESCRIPTION. APPLICANT AND OR CONCERNED PARTY (S) ACKNOWLEDGE PAGES 1 – 7 HEREIN.
OYCP’s selection considerations include the safety and success of Candidates and Staff. INTRODUCTION Applying for enrollment into the Oregon National Guard Youth Challenge Program is comparable to applying for work in any private, business or state agency. If the application is incomplete in anyway, or if the handwriting or documents are not legible, your application will not be processed. Just like any job/position that one would apply for, the applications must clearly show qualifications or the potential eligibility for entry into that placement; OYCP is no different. The application is the foundation of accountability, integrity and responsibility among other OYCP components that are actively practiced. These values are taught as CORE Components and are an OYCP tradition. The application must be complete; every question is to be answered. If a question(s) does not apply, write “N/A or NONE” next to the question(s). When OYCP receives an enrollment application it is only the first phase of review that the application must go through for selection and placement into the program. Applying to OYCP does not mean automatic acceptance. OYCP is selective and will admit applicants that are most likely to succeed in this type of program. Applications are approved or denied by the OYCP Selection Committee. To attend OYCP the applicant must meet the eligibility criteria. This is a once-in-a lifetime second chance educational opportunity to become a student of the Oregon National Guard Youth Challenge Program. ENROLLMENT APPLICATION The enrollment application is available and can be downloaded and printed from the website at www.oycp.com complete and return the application to OYCP as early as possible. The application will be screened to determine if the applicant meets the basic eligibility requirements. It will then be forwarded to the appropriate agency(s) for the mandatory criminal background check (this process may take up to three weeks to complete). During the background check, the applicant and parent(s) are to make plans to attend a required orientation (information is posted on the OYCP website). Call 541-317-9623 ext. 223 to reserve a seat for that date, as space is limited. Priority consideration for placement will be given to the applicant who attended the mandatory orientation along with their parent(s). OYCP will call or mail correspondence to the applicant regarding status of eligibility. TWO (2) MENTOR APPLICATIONS Mentor applications are available and can be downloaded and printed from the website at www.oycp.com Two separate prospective mentors must complete an application (one application per mentor). The mentor applications must be received by: Oregon National Guard Youth Challenge Program 23861 Dodds Road Bend, Oregon 97701 It is recommended that the mentor applications be submitted along with the enrollment application. The student will not enter the program until OYCP receives two complete mentors applications. For this specific program the Mentor must: be willing to commit for 17½ months, be of the same gender as the applicant, be 21 years of age or older and live within the same geographic proximity, be able to pass a criminal history check, and be able to attend the required six-hour training at th OYCP in Bend, Oregon on or about the 13 week after the applicant is enrolled in the program. The mentor is not to be a relative (bloodline or marriage). God-parents are not to be mentors. The mentor and mentee must make four (4) contacts per month; two of these contacts must be face to face. Mentors may be anyone willing to commit and meet all OYCP requirements. Examples of mentors are: Friends of the family, a neighbor, a member of your local church congregation, YMCA/YWCA Representative, Boys/Girls Club Representative, Big Brother/Sister Representative, Law Enforcement Representative, a Firefighter, even a Teacher to name just a few. To begin your quest, place emphasis on someone you already know. This will make the process easier. Without two (2) mentor applications, enrollment will be denied. ACCEPTANCE LETTER Due to the high volume of enrollment applications and all proper steps that are required to assess, gather and verify, for each; the acceptance letters are mailed out approximately one (1) month before the start date of the program. A formal letter of acceptance will be sent to the applicant authorizing him/her to attend OYCP. The letter that one receives is exclusive. No one enters the Oregon National Guard Youth Challenge Program without receiving the official acceptance letter. It is important to follow the detailed instructions in this letter, it will help answer questions that you have or that arise during your preparation and waiting period.
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YOUTH CHALLENGE PROGRAM RULES AND REGULATIONS – OYCP ENROLLMENT “I will honor my commitment to complete the program. I will not leave the course site, run away or hide. I will not lie, cheat or steal or tolerate others who do.” The 2-week Pre-Challenge Phase is conducted in residential status at the program facility in Bend, Oregon. This is the trial period in which each student is given a chance to prove his or her commitment to the program. A cut may be done at the end of this Phase. After successful completion of Pre-Challenge, students enter the 20-week Challenge Residential Phase. During the 22-week Residential Phase, there is one family visitation at the program facility that is scheduled in advance by OYCP. For purposes of security, safety and control the following requirements ARE policy: Visitors are limited to parents, legal guardians, siblings, and/or grandparents. Girlfriends/Boyfriends are NOT to attend visitation. Visitors are required to remain inside the building for the duration of their visit. Once leaving the building, re-entry will not be permitted. Visitors must leave unnecessary items in their vehicles (i.e., purses, briefcases, backpacks, fanny packs, etc.). Items brought into this Federal facility are subject to search by staff. Visitors will remain in the designated visitation area. Staff members will be present and available for questions and answers. Students agree to the following: Rules in the “Cadet Manual” are mandatory and will be followed. Follow rules and conditions as stated within the program outline, listen, obey and follow through with all orders and commands that are given by the staff, instructors and/or administrative personnel both oral and written. An order or directive compromising the safety, well-being and integrity of all concerned will not be given. No hairpins or barrettes No phone privileges No Smoking Jewelry of any kind is not allowed Money will NOT be sent or given Boyfriend/girlfriend relationships will not be permitted or tolerated Attend all classes March in formation Be silent (unless ordered otherwise) Participate in class studies focusing on high school credits, GED or high school diploma Participate in community service. Community service involves physical exertion and travel throughout the community Participate in Physical Training. (P.T.) Maintain daily personal hygiene Actively keep the safety and well being of others a priority at all times This is a “Drug Free Program” any use, or attempt to use, will not be tolerated and will result in immediate discharge from this program.
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Staff or facility personnel will confiscate contraband. (Such items include, but are not limited to: make-up, weapons, gum, jewelry, electronic devices, lighters/matches, etc.). Personal belongings, including mail, will be searched for contraband. YOUTH CHALLENGE PROGRAM RULES AND REGULATIONS – OYCP ENROLLMENT (cont.) Any assault or contact (physically, verbally or sexual) including provoking, bothering, irritating or teasing people or encouraging others to do the same will not be tolerated. Follow instructions given by staff or volunteers Be on time to all sessions, formations, classes and meetings in the proper uniform and with the proper equipment Clean and maintain all areas, respecting the property area of others. Do not deface, destroy, write, mark or graffiti on oneself, clothing, equipment or property Clean the living quarters, bathroom and kitchen every day Address peers and staff by last name Use the chain of command to resolve complaints or issues Wear the OYCP uniform with pride. (i.e., no sagging pants, shirt will be tucked in, etc.) Representing a gang with graffiti, hand signs, body stance, sneaker shoestrings, or other ways of wearing clothing that may appear gang related is not tolerated. Inform staff of medications prescribed by a licensed medical provider. Report all injuries/illnesses to OYCP staff in order to receive timely and appropriate treatment. The OYCP Certified Nurse Practitioner will evaluate health, welfare and comfort of each student. Abide by OYCP safety instructions, standards and rules Damage or destruction to OYCP property caused by applicants personal negligence, at will or knowledge, will be paid in full amount by the applicant and/or parent(s)/legal guardian(s). (OYCP reserves the right to set the damage costs) There are risks while participating in program activities. Such activities include and are not limited to the following: sports injuries, illness, accidents while traveling in vehicles or aircraft, injury while participating in community projects or any other activities deemed proper by the Director of the Program. To participate in the Oregon National Guard Youth Challenge Program, applicants hereby release and forever discharge the United States and the State of Oregon, their officers, agents, and employees acting officially or otherwise, from any and all claims, demands, actions, or cause of action, on account of any injury/illness to me which may occur from any cause arising out of his/her participation in the Program. To give permission OYCP staff for the purpose of conducting “health and welfare” inspections to include searches, of personal property and belongings as deemed necessary by the Program Director To give permission to have photos taken and/or to be interviewed for purposes of brochures, newsletters, media, slide presentations and other publications BENEFITS OF GRADUATING OYCP ARE: Military branches accept OYCP Graduates with a Diploma. Each graduate receives a letter of recommendation from the Director. Academic and vocational experience to succeed. Personal growth, self-esteem and confidence. The chance of successfully re-entering high school to achieve a diploma.
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THIS IS A VOLUNTARY PROGRAM The opportunity to request permission to leave is afforded. Permission to voluntarily leave must go through the Program Director and can only be requested through staff. Any request to leave must be made Monday through Friday, 9 a.m. to 4 p.m. Procedure for leaving includes contact with referring agency, guardian and/or parent who are responsible for providing transportation home from the facility. No one under the age of 21 is authorized to pick-up any cadet. YOUTH CHALLENGE PROGRAM RULES AND REGULATIONS – DRUG POLICY DRUG POLICY It is the policy of the Oregon Youth Challenge Program, National Guard Bureau and our Congressional sponsors that the program be a “Drug Free” alternative for “At Risk” youth. Drug free means that an applicant must show no signs or indicators on the first day of Pre-Challenge of drug use as determined by a voluntary drug detection screen administered by the program. DRUG TEST OYCP uses a nationally approved portable test that is used by numerous treatment, corrections and juvenile system programs. Our interest is to administer the screen objectively with the intentions of accepting all applicants. However, a positive result will eliminate an applicant from acceptance into the current class he/she applied for. Do not eat any foods that could/should/would show up in the drug screen as a positive test. (Poppy seed muffins, breads etc.) If you do, you will not enter the program. A diluted specimen is considered a positive trace and will prohibit acceptance into the OYCP program. WHAT ARE MY OPTIONS? If the drug screen resulted as a positive test, the following is an option: You may seek an independent drug screen from a certified medical facility within Twenty-four (24) hours. You must provide an original copy of a negative drug screen result, dated and signed by an authorized medical official from a testing facility and provide it to OYCP immediately within 24 hours. OR You may return home and apply for the next Youth Challenge class. YOUTH CHALLENGE PROGRAM RULES AND REGULATIONS – PARENT REQUIREMENTS Oregon’s National Guard Youth Challenge Program is not for every student. However, those students that do “take the Challenge” and complete the program often turn their life around. Our 17½-month program requires a commitment from both the student and parent/guardian to participate for the entire duration. During this period, the National Guard will expend nearly $16,000 per student to help your daughter/son address a number of life issues including their continued education. OYCP is not a drop-off point for parents/guardians to hand over parental responsibilities. Instead, it is a partnership and parents must be willing to participate and continue to support their child emotionally and financially. The parent/guardian must be willing to attend the scheduled visitation during the class without exception. This is an important part of our work at “Challenge” and you must be willing to participate if you send your child here. If you choose not to participate after your child is enrolled your child will be returned home immediately by bus transportation at your expense. The parent/guardian must be willing and agree to pay for ALL medications, prescriptions drugs and emergency dental/medical/optometry care through coordination with “Challenge” staff. The parent/legal guardian must provide routine medication(s) to OYCP on a monthly basis if no arrangements have been made at the Bend, Oregon Safeway Pharmacy. This process/procedure must be in place before the class starts. If your child does not have medical insurance contact and communicate with: Oregon Health Plan 1-800-359-9517 or 24-hour School Insurance 1-800-767-0700 ext. 3 P.O. Box 809066, Dallas, TX 75380
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ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
website: www.student-resources.net When applying for 24 hour Student Health Plan/Accidental School Insurance, clearly indicate: “BEND/LaPINE SCHOOL DISTRICT” You must pay for prescriptions/drugs. We will attempt to contact the parents/guardians no more than twice to seek assistance. If we do not receive parent/guardian assistance/intervention for payment or medical care, the candidate is returned home immediately by bus at parent/guardian expense. YOUTH CHALLENGE PROGRAM RULES AND REGULATIONS – PARENT REQUIREMENTS (cont.) A physical examination must be completed and provided within a 90-day window prior to the “Challenge” program. This is the parent/guardian responsibility. The completed form must indicate a medical history and be signed by a licensed physician that your child can physically participate. If it is learned later during the program that a prior health or injury condition existed that was not revealed, the cadet may be returned home. It is imperative that any injury, or condition is disclosed and does not/will not interfere with daily physical training. The applicant, parent/guardian are responsible for ensuring that two reputable mentor prospects are provided to OYCP before the candidate will be accepted. The mentor requirement is the most important part of the Post Residential phase of OYCP. If complete mentor applications are not presented with the enrollment application the result will be a rejected OYCP application. A drug test will occur on the day your daughter/son arrives for inprocessing. If the urinalysis result is positive, your daughter/son will be returning home with you and may apply for the next class. Be sure your daughter/son is “Drug Free” when they arrive. This is a National Guard mandate. Your attention to this important requirement will avoid embarrassment and ensure eligibility when you arrive. The parent/guardian is responsible to ensure that their daughter/son is picked up and returned on time to OYCP during school closures. OYCP will be closed during Spring Break, Memorial Day weekend, Labor Day weekend and Thanksgiving weekend, just like the other Oregon School Districts. We will not be responsible for your child’s transportation. A drug test will be administered to all students when they return from these school closures. A positive urinalysis will result in immediate termination from OYCP. The parents/guardian are responsible to ensure that incidentals such as soap, shampoo, under clothes, boots etc. are provided to their daughter/son for inprocessing and as required throughout the Residential Phase. For a candidate to be accepted into the program, parents/guardians must be willing to accept responsibility (pay) for any damage deliberately done to the OYCP facility or guest property in the community while actively involved in community service. An investigation will be completed to validate the circumstance. If parents do not accept this responsibility, the cadet will be terminated and formal payment proceedings initiated. Your son/daughter will be sent home at your expense if there are unresolved issues (domestic or otherwise) that will distract and or inhibit the child’s performance at OYCP. It is expected that parent(s) and the youth act as responsible adults. Any uncalled-for, willful actions will be grounds for dismissal from OYCP. This applies to all parties involved.
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YOUTH CHALLENGE PROGRAM RULES AND REGULATIONS AND JUSTIFIED REASONS FOR TERMINATION This is a common question asked by potential students and their parents/guardian. Like any other program or school, there are “values”, rules and expectations. In addition, OYCP is voluntary… your daughter/son can leave at any time voluntarily. Like-wise, we can and will send participants home “voluntarily”. We will do what is possible to help your child succeed and normally extend numerous opportunities to succeed through the counseling, feedback, infraction and disciplinary process. However, we reserve the right to send your child home and will exercise that right if progress is not made according to our standards.
“OYCP IS A PRIVILEGE NOT A RIGHT”
The following are primary reasons students will be terminated from OYCP: Continuous disruptions and/or disorderly conduct that prevent teachers and staff from assisting your child and/or students in the program. We will not tolerate participants and parent(s) that disrupt the progress and growth of others. The Director will make this decision. There is zero tolerance for any drug activity or drug contraband that enters into the program either directly or indirectly. All participants will take a required drug test after all passes, extended community visits, holiday school closures and randomly. This is a condition of attendance at OYCP. Drugs are strictly prohibited and jeopardize our funding, health and welfare of cadets, staff, teachers and the National Guard as our program sponsor. Expulsion will occur if the cadet has not responded positively and made progress within the 8 CORE component requirements after receiving counseling from the Platoon Leader, staff, and been through peer court, Commandant counseling and the expulsion board. In the event a student no longer wants to participate or refuses to comply with program and staff requirements…they will be sent home. We cannot assist students who just refuse to abide by and follow direction. They disrupt the other cadets who want to be here and make changes in their lives. We will give fair and just effort to help your child succeed. Extensive and deliberate damage to our building or facilities will result in expulsion and parents/guardian charged for the damage. This is an entrance requirement and condition of acceptance to OYCP. Injuries dental/medical issues that interfere with or prohibit daily participation in all activities Mental Health issues including depression, talk or threat of suicide and psychological disorders/disruptions
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A BETTER OREGON… ONE YOUTH AT A TIME
STUDENT ENROLLMENT APPLICATION
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
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NATIONAL GUARD BUREAU and THE STATE OF OREGON MANDATED ELIGIBILITY CRITERIA
1. High Priority: Two complete mentor applications must represent this enrollment application. You may submit the mentor applications along with this enrollment application or you/the mentor may mail the applications at a later date. Completed mentor applications must be in the possession of OYCP no later than 30 days prior to the program start date. Give each prospective mentor (1) application to complete for a total of (2) applications. 16 – 18 years of age at time of entry date into the program. Definition: If the applicant is 15 years of age or younger or is 19 years of age on the day of class commencement, acceptance into the program will be denied A School Drop Out/At-Risk of dropping out of school (page 16 of enrollment application) Definition: A general term that describes a youth who is no longer attending any school and who has not received a secondary school diploma or a certificate from a program of equivalency for such diploma – or due to a consistent/historic pattern, trend or indicating factors of the individual having a high propensity/potential for dropping out of school A citizen or legal resident of the United States and a resident of the state in which the program is operated Unemployed - Definition: An individual who is not regularly employed in full time work Not on parole/probation, not awaiting sentencing, not under indictment, charged, or adjudicated/convicted of a felony (prior history of assault/sexual offenses may prohibit review of the application and enrollment into OYCP) Free from the use of illegal drugs or substances (selected applicants will be tested – outcome is either pass/fail) Physically and mentally capable to participate in the program with reasonable accommodations for physical and other disabilities GENERAL INSTRUCTIONS A) The applicant, parent(s)/legal guardian(s) are to review the enrollment application and self-screen for potential eligibility. After having read and understanding the program’s enrollment eligibility criteria and if the applicant feels that he/she is potentially eligible, apply. Next, the applicant, parent/guardian attend a mandatory orientation B) if applicant is found to be eligible to participate in the program and remains a committed volunteer, OYCP will grant priority placement for him/her (applicant).
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1. Obtain an enrollment application from: Oregon National Guard Youth Challenge Program’s Web Page at: www.oycp.com -OR- (541) 317-9623 ext. 223 Oregon National Guard Youth Challenge Program 23861 Dodds Road Bend, Oregon 97701 2. Complete the enrollment application: Remember, two (2) mentor applications must represent the enrollment application weather the mentor applications are submitted with the enrollment application or not. Submit the applications no later that 30 days before the program begins. 3. Signature: By signing, you agree to the conditions stated throughout the application including disclosed rules and regulations the certification and signature section of the application. When submitting a hard copy, type/print clearly in black ink and sign the application in ink. 4. Submit current legible copies of the application materials requested School Transcript(s): (dating back to the last time you attended school, alternative/other) Students receiving instruction for Individualized Education Program (I.E.P.) or Special Education are to submit documentation Medical, Dental, Vision Insurance Card: (front and back clearly indicating applicant as a/the beneficiary) Immunization Record/Vaccination: (Shot Record) Birth Certificate Oregon Photo Identification: (drivers permit, drivers license, school I. D. card, personal I. D. card, other) Court Generated/Legal Document(s): (divorce, legal guardianship, adoption, foster care, court order, etc.) 5. Incomplete or illegible applications (including faxed applications) will not be accepted. Youth Challenge is not responsible for applications that are misdirected, lost in the mail, or lost as a result of transmitting by fax or email. Recommendation: Keep a copy of your application materials. OYCP will not provide copies. OYCP’s MISSION To provide opportunities for personal growth, self improvement and academic achievement among Oregon high school drop outs, youth no longer attending and those failing in school, through a highly structured nontraditional environment; integrating training, mentoring and diverse educational activities. OYCP’s GOAL Each cadet will continue in one or in combination of the following: Secondary Education (re-enter high school) Post secondary education (college) Vocational Training Full time employment Have placement before OYCP graduation
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OREGON NATIONAL GUAR D YOUTH CHALLENGE PROGRAM EIGHT CORE COMPONENTS (NATIONAL GUARD BUREAU MANDATED) LEADERSHIP/FOLLOWERSHIP Learn positive leadership responsibilities, followership responsibilities, and roles within social groups. RESPONSIBLE CITIZENSHIP Understand civic responsibilities and the role of a positive citizen within the community. ACADEMIC EXCELLENCE Increase grade levels in reading and mathematics, attain a GED or high school diploma, and pursue higher education. JOB SKILLS Learn basic work skills, resume writing, job interview techniques, and career exploration. LIFE COPING SKILLS Learn personal financial management, teamwork skills, anger management, and drug and alcohol avoidance strategies. HEALTH AND HYGIENE Understand nutrition basics, substance abuse awareness, and personal relationships COMMUNITY SERVICE Give back to the community by performing a minimum of 40 hours of community service. PHYSICAL FITNESS Improve personal fitness through daily exercise activities and intramural sports.
O.N.G.Y.C.P. APPLICANT DOCUMENT CHECKLIST and TABLE OF CONTENTS
PAGES ONE – SEVEN (1 – 7) OREGON NATIONAL GUARD YOUTH CHALLENGE PROGRAM RULES AND REGULATIONS (NOT REQUIRED TO BE SUBMITTED – APPLICANT AND PARENT MUST READ AND UNDERSTAND) PAGE EIGHT (8): STUDENT ENROLLMENT APPLICATION COVER PAGE (NOT REQUIRED TO SUBMIT) PAGE NINE (9): NATIONAL GUARD BUREAU AND STATE OF OREGON MANDATED ELIGIBILITY CRITERIA/GENERAL INSTRUCTION (NOT REQUIRED TO BE SUBMITTED) PAGE TEN (10): OYCP’s MISSION/GOAL/8 CORE COMPONENTS OUTLINE (NOT REQUIRED TO BE SUBMITTED) PAGE ELEVEN (11): APPLICANT DOCUMENT CHECKLIST AND TABLE OF CONTENTS (NOT REQUIRED TO BE SUBMITTED – KEEP THIS FOR YOUR RECORDS AS A REFERENCE SHEET) PAGES TWELVE (12): YOUTH CHALLENGE PROGRAM STUDENT ENROLLMENT APPLICATION (PAGES 12-21) (COMPLETE THE APPLICATION IN BLACK OR BLUE INK, TO INCLUDE SIGNATURE PAGES AND SUBMIT TO OYCP)
LIST AN APPOINTED EMERGENCY CONTACT/RELEASE PERSON (NAME, PHONE/S, ADDRESS, ETC.)
PAGE THIRTEEN (13): ENROLLMENT STATISTICAL INFORMATION (COMPLETE AND SUBMIT TO OYCP) PAGE FOURTEEN (14): APPLICANT SELF-LETTER OF RECOMMENDATION (COMPLETE AND SUBMIT TO OYCP) PAGE FIFTEEN (15): APPLICANT GOALS (COMPLETE AND SUBMIT TO OYCP)
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PAGE SIXTEEN (16): DROP OUT RISK FACTOR VERIFICATION AND TRANSCRIPT REQUEST FORM (TO BE COMPLETED BY A SCHOOL ADMINISTRATOR/REPRESENTATIVE AND SIGNED. COMPLETE AND SUBMIT TO OYCP) PAGE SEVENTEEN (17): OYCP UNDERSTANDING OF: LIMITED MEDICAL SERVICES (SIGNED AND SUBMITTED WITH REQUIRED OYCP PHYSICAL) PAGE EIGHTEEN (18): MEDICAL RELEASE – CONSENT TO TREATMENT OF MINOR CHILD (TO BE COMPLETED AND SIGNED BY APPLICANT, CUSTODIAL/(LEGAL) GUARDIAN AND LICENSED MEDICAL PROVIDER) (COMPLETE AND SUBMITTED TO OYCP) PAGE NINETEEN (19): PRE-PARTICIPATION PHYSICAL - (TO BE COMPLETED AND SIGNED BY A LICENSED MEDICAL PROVIDER) (COMPLETE AND SUBMIT TO OYCP) PAGE TWENTY (20): CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (COMPLETE AND SUBMIT TO OYCP. MUST BE SIGNED BY THE CUSTODIAL LEGAL PARENT/GUARDIAN AND STUDENT) PAGE TWENTY-ONE (21): APPLICATION CERTIFICATION AND SIGNATURE (COMPLETE AND SUBMIT TO OYCP) PAGES TWENTY-TWO – THIRTY-ONE (22 - 31): MENTOR APPLICATION BOOKLET #1 (PAGES 26 – 29 TO BE COMPLETED BY THE MENTOR AND SUBMITTED BY MAIL TO OYCP) (PAGES 30, 31 ARE FORWARDED BY THE PROSPECTIVE MENTOR TO TWO (2) PERSONAL REFERENCES OF THE MENTOR. ONCE COMPLETE, THE PERSONAL REFERENCES OF THE MENTOR SUBMIT THE FORM TO THE ADDRESS LISTED BY OFFICIAL MAIL) PAGES THIRTY-TWO – FORTY-ONE (32 - 41) MENTOR APPLICATION BOOKLET #2 PAGES 36 – 39 TO BE COMPLETED BY THE MENTOR AND SUBMITTED BY MAIL TO OYCP) (PAGES 40, 41 ARE FORWARDED BY THE PROSPECTIVE MENTOR TO TWO (2) PERSONAL REFERENCES OF THE MENTOR. ONCE COMPLETE, THE PERSONAL REFERENCES OF THE MENTOR SUBMIT THE FORM TO THE ADDRESS LISTED BY OFFICIAL MAIL)
SUBMIT CURRENT LEGIBLE COPIES OF: (each on a separate sheet of paper or accordingly)
SCHOOL TRANSCRIPT(S): (DATING BACK TO THE LAST TIME APPLICANT ATTENDED SCHOOL, ALTERNATIVE OR OTHER) (PROVIDE DOCUMENTATION OF INSTRUCTION FOR INDIVIDUALIZED EDUCATION PROGRAM (I.E.P.) OR SPECIAL EDUCATION) MEDICAL, DENTAL AND VISION INSURANCE POLICY CARD: (FRONT AND BACK CLEARLY INDICATING YOU ARE A/THE BENEFICIARY) IMMUNIZATION/VACCINATION RECORD: (SHOT RECORD) BIRTH CERTIFICATE OREGON PHOTO IDENTIFICATION: (DRIVERS PERMIT, DRIVERS LICENSE, SCHOOL I. D. CARD, PERSONAL I. D. CARD) COURT/(LEGAL) DOCUMENT(S): (DIVORCE/LEGAL GUARDIANSHIP/ADOPTION/FOSTER CARE/COURT ORDER, ETC.) RELEASE FROM COMPULSORY SCHOOL ATTENDANCE (ACQUIRE THIS FORM FROM YOUR SCHOOL) ONLY IF YOU ARE SELECTED TO ATTEND OYCP IS THE RELEASE EFFECTIVE AND IT IS EFFECTIVE THE DAY OYCP BEGINS. (THE FORM IS TO BE OBTAINED FROM THE SCHOOL THAT YOU CURRENTLY ATTEND. THE FORM IS TO BE SIGNED BY THE APPROPRIATE SCHOOL ADMINISTRATOR TO INCLUDE YOUR PARENT(S)/LEGAL GUARDIAN(S) SIGNATURE. ONCE COMPLETE SUBMIT TO OYCP) IF YOU ARE A SCHOOL DROPOUT…DISREGARD/DO NOT COMPLETE THE RELEASE FROM COMPULSORY SCHOOL ATTENDANCE. YOU’RE A SCHOOL DROPOUT!
Do not deliberately drop out of school to attempt to meet YCP’s school drop out status. Allow your enrollment application to be reviewed/screened to determine potential eligibility.
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YOUTH CHALLENGE PROGRAM STUDENT ENROLLMENT APPLICATION
APPLICANT MAIN INFORMATION Last Name (True)_______________________________ First Name (True)__________________________ MI_____ Suffix: Jr. Sr. I II III IV Date of Birth: (mm/dd/yyyy)___________Age___ Gender Male Female Ethnicity: American Indian/Alaskan Asian/Pacific Islander Black (not of Hispanic Origin) Hispanic Multiracial Other White (not of Hispanic Origin) Married: Yes No # of Children___# in household___Family $: 15-25K 25-35K 35-45K 45K+ <15K Applicant: Do you have/participate in an Individual Education Plan (I.E.P.) Yes No APPLICANT CONTACT INFORMATION/ADDRESS Home Phone__________________ Work Phone________________Ext._______Email_____________________________ Fax________________Cell Phone_________________Pager________________Message Phone ___________________ County______________________#1 Address___________________________#2 Address__________________________ City State Zip Code Applicant: Is this your mailing address? Yes No #1 PARENT(S)/GUARDIAN(S) STATUS/ADDRESS: Relation to applicant: Grandparent/s Legal Guardian/s Other Parent/s Sibling Spouse Step-Parent/s Last Name____________________________First Name________________________ Middle Name__________________ Suffix: Jr. Sr. I II III IV Home Phone_________________ Work Phone_________________Ext.______Email______________________________ Pager____________________Cell Phone___________________ Authorized for applicant pickup: Yes No Legal Guardian: Yes No Are you the Emergency Contact for the applicant? Primary Secondary No #1 Address_________________________________________ #2 Address_______________________________________ City State Zip Code Parent/Guardian: Is this your mailing address? Yes No # 2 PARENT(S)/GUARDIAN(S) STATUS/ADDRESS Relation to applicant: Grandparent/s Legal Guardian/s Other Parent/s Sibling Spouse Step-Parent/s Last Name____________________________First Name________________________ Middle Name__________________ Suffix: Jr. Sr. I II III IV Home Phone__________________ Work Phone________________Ext.______Email______________________________ Pager____________________Cell Phone___________________ Authorized for applicant pickup: Yes No Legal Guardian: Yes No Are you the Emergency Contact for the applicant? Primary Secondary No #1 Address_________________________________________ #2 Address_______________________________________ City State Zip Code Parent/Guardian: Is this your mailing address? Yes No APPOINTED EMERGENCY CONTACT/RELEASE PERSON (requirement: 21 years of age/older, provide valid drivers license/I.D.) Relation to applicant: Grandparent/s Legal Guardian/s Other Parent/s Sibling Spouse Step-Parent/s Last Name____________________________First Name________________________ Middle Name__________________ Suffix: Jr. Sr. I II III IV Home Phone__________________ Work Phone________________Ext.______Email______________________________ Pager____________________Cell Phone___________________ Authorized for applicant pickup: Yes No Legal Guardian: Yes No Are you the Emergency Contact for the applicant? Primary Secondary #1 Address_________________________________________ #2 Address_______________________________________ City State Zip Code Parent/Guardian: Is this your mailing address? Yes No EDUCATION INFORMATION Name of last School Attended: The date you last attended school: NAME OF THE PERSON WHO REFERRED YOU TO THE YOUTH CHALLENGE PROGRAM Last Name First Name Occupation INSURANCE INFORMATION Type of Insurance: Dental Eye Medical Prescription Group#___________________________ Policy#______________________________ Expiration Date________________ Physician ________________________________ Phone_______________________ Fax__________________________ Co-pay information:___________________________________________________________________________________ Policy Holder (Name)_________________________________________ Relation to applicant: Grandparent/s Legal Guardian/s Other Parent/s Sibling Spouse Step-Parent/s Insurance Company (Name)___________________________________Phone__________________Fax______________ #1 Address_______________________________________#2 Address_________________________________________ City State Zip Code
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 13 OF 41
O.N.G.Y.C.P. ENROLLMENT STATISTICAL INFORMATION (to be completed by applicant)
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 14 OF 41
EDUCATION GED HS Freshman HS Sophomore HS Junior HS Senior HS drop out Other_________________ Special Education Student? Yes No When did you dropout of school? 1-3 wks 1 mo. 3 mo. 6 mo. 9 mo. 1yr. 2yr. 3yr. 5yr. + How many times have you been suspended from school?__________ Are you home schooled? Yes (via parent/guardian or recognized school association_____________________) No MEDICAL 6. Indicate last date of the following: Medical check:_____________Dental check:___________Vision check:__________ 7. Are you a smoker? Yes No 8. Are you affiliated with or have a history of gang relations? Yes No 1. 2. 3. 4. 5. 9. What illegal drugs have you used and how long ago? a) drug_______________when______ b) drug________________when______ c) drug_________________when_______ d) drug_______________when______ e) drug________________when______ f) drug_________________when_______ 10. What medication(s)do you receive?: a)______________________________ b)_______________________________ c)_______________________________d)______________________________ e)_______________________________ 11. What medication(s) did you take in the past 12 months that you do not take now?: a)__________________________ b)____________________ c)_____________________ d)___________________ e)______________________________ BASIC/MISCELLANEOUS INFORMATION 12. Do you or a member of your family receive Public Assistance (Food stamps, Cash Assistance or other?) Yes No 13. What type of public assistance? Food Stamps Cash Aid Medical Free/Reduced school lunch Other 14. Public assistance caseworker(s) Name_________________________ Phone_________________ Fax____________ 15. Are you in the care, custody and supervision of the state of Oregon (ward of the state of Oregon)? Yes No 16. Are you in the care, custody and supervision of the court/judicial system (ward of the court)? Yes No 17. How long have you lived in Oregon?_________ 18. Do you intend to stay in Oregon? Yes No 19. How many times have you been arrested?____ a) date____________ crime ________________________________ b) date__________ crime ________________________ c) date____________ crime_____________________________ 20. Where were you born, what state?______________________________________________ 21. What state did you live in before you came to Oregon? State___ City__________________County_______________ 22. Why did you move to Oregon?______________________________________________________________________ __________________________________________________________________________________________________ 23. Are your parents Legally separated Yes No 24. Are your parent(s) legally divorced Yes No 25. Who do you live with? Grand-parent/s Legal Guardian/s Other Parent/s Sibling Spouse Step-Parent/s 26. Have you attempted suicide? Yes when?________________how?_________________________________ No 27. Have you attended anger management? Yes No 28. Have you been diagnosed with depression? Yes No 29. Have you been in a residential treatment program? Yes No 30. Are you a Foster Child Yes No 31. Are you Adopted Yes No 32. Are you Homeless Yes No 33. Are you a School Dropout Yes No 34. Are you Attention Deficit Disorder? (ADD) Yes No 35. Are you Attention Deficit Hyperactive Disorder? (ADHD) Yes No 36. Do you know anyone else that is applying for this same class that you are? Yes No (Name)__________________________Relationship to you?_______________________________________ Yes No (Name)__________________________Relationship to you?_______________________________________ Yes No (Name)__________________________Relationship to you?_______________________________________ HOW DID YOU FIND OUT ABOUT YOUTH CHALLENGE PROGRAM? Newspaper (list publication)_______________________ Friend Website HS Counselor Media YMCA Law Enforcement Agency Juvenile Department Employment Department Services to Children and Families Department of Human Resources/Self Sufficiency Center Armed Forces Recruiting Office Former OYCP Cadet Boys and Girls Clubs of America Transient Shelter Other (describe)_____________________________________ APPLICANT CLOTHING SIZES (SMALL, MEDIUM, LARGE, X-LARGE, OTHER) Applicant Name__________________________
HAT SIZE:___________ Applicant Comment:
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 15 OF 41
SHIRT SIZE:__________
PANT SIZE:__________
BOOT SIZE:__________
O.N.G.Y.C.P. APPLICANT SELF- LETTER OF RECOMMENDATION
Applicant: On this page sell yourself to OYCP. Why should you be selected for this program over anyone else? Remember: OYCP is selective and will exercise the right to choose the applicant most likely to succeed in this program.
Applicant Name_____________________________________________________________Date__________________
_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 16 OF 41
O.N.G.Y.C.P. APPLICANT GOALS (to be completed by the prospective applicant)
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 17 OF 41
The National Guard Challenge Program is committed to the education of young people. Success in this program requires careful planning, personal commitment, hard work, and a clear focus. In order to maximize the benefits of this program, you must be focused with clear goals. Your answers will be used to guide your interview. OYCP will not consider your application unless your placement and goals are clearly listed. If you are selected, you must successfully complete all eight ChalleNGe core components and meet the following “placement” definition: If selected to attend OYCP and the GED diploma is not attained during enrollment, I agree to: 1) Be enrolled in continuing education to either attain a GED or high school diploma 2) Be enrolled in trade/vocational school 3) Be enrolled (in either #1 or #2) and be employed part time If selected to attend OYCP and the GED diploma is attained during enrollment, I agree to: 4) Be enrolled in trade/vocational school 5) Be enrolled in higher education 6) Be enrolled (in either #4 or #5) and be employed part time 7) Be employed in a full time status
A) Write a paragraph of what your life will be like at the end of the Challenge Program, a year and a half from now. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ B) List your goals for the next year and a half. (Goal # 1= 6 month, Goal # 2= 12 month, Goal # 3= 18 month) Goal #1: ____________________________________________________________________________________ ____________________________________________________________________________________
Goal #2: ___________________________________________________________________________________ ___________________________________________________________________________________
Goal #3: __________________________________________________________________________________ __________________________________________________________________________________
C) How can the National Guard Challenge Program help you achieve these goals? ___________________________________________________________________________________________ ____________________________________________________________________________________________
Mandatory “Placement” To Graduate - Definition: In order to be accepted in to the program and to graduate from OYCP, the applicant/graduate must have a “placement” back in the community in high school, job, military, vocation, college, volunteer experience or other approved placement before graduation. You must have a placement plan and be pursuing that plan while at OYCP. You must show proof of the placement that will take place upon your graduation or the applicant is not eligible for certificate of graduation. I understand that I cannot be considered or graduate from OYCP without a “placement” as described (twice) on this page. Yes No
FOR INTERNAL USE ONLY --------------------------------------------------------------------------------DO NOT WRITE BELOW THIS LINE-------------------------------------------------------------------------------Based on the interview with this applicant, Does the applicant clearly understand and communicate his/her goals? Yes No Are the goals aligned with the National Guard Challenge Program services? Yes No Can this applicant be served well by the Challenge Program? Yes No
OYCP Staff signature:
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 18 OF 41
Date
O.N.G.Y.C.P. DROPOUT RISK FACTOR VERIFICATION and TRANSCRIPT REQUEST FORM
(To be completed, signed and dated by school administrator. Student, parent/legal guardian sign and date)
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 19 OF 41
(MARK THE BOX(S) (
) BELOW AS APPROPRIATE) STUDENT’S NAME (PRINT)______________________________________________ YOUTH AT-RISK OF DROPPING OUT OF SCHOOL VIA LOSS OF ACADEMIC SUCCESS AS EVIDENCED BY:
Basic skill deficiency (behind at least two or more grade levels in math, reading, or language arts as determined by school district records) Behind in school credits (at least one school year) Failing grades (failure of two or more non-elective classes) Age at least two years above the normal age for youth’s grade level Economically disadvantaged: (1) Receives or is a member of a family that receives cash welfare payments under a Federal, State or local welfare program; or (2) has, or is a member of a family that has, received a total family income for 12 months (or 6 month, annualized, if 12 month data are not available) period prior to application to the program which, in relation to family size, was not in excess of the higher of: (a) The poverty level determined in accordance with criteria established by the Department of Health and Human Services; or (b) 70% of the lower living standard income level; or (c) is receiving food stamps pursuant to the Food Stamp Act of 1977 as amended; or (d) is a foster child on behalf of whom the State or local government payments are made; or (e) is homeless. Educationally disadvantaged limited basic skills limited English proficiency Significant number of absences or erratic attendance resulting in the youth not benefiting from school Behavior disorders disruptive antisocial substance abuse poor self-concept severe discipline problems Teen parent ages 16-18 married unmarried Offender or prior involvement with, or diverted from a State or local criminal justice system Learning disability constituting or resulting in a substantial barrier to Education or Employment Total credit(s) applicant earned in the following: English______ Math______
Reading_____
Last full grade completed______
Writing_____ Speaking_____ Math_____
Testing Information/Proficiency Tests (P=Passed, F=Failed, NT=Not Taken)
School Administrator:
At my level of professional experience/knowledge and based upon the dropout factor(s) indicated above and under the circumstances (current/historical) if this youth does not attend OYCP (as intervention) toward a second chance opportunity to earn his/her education,
I DO FIND
I DO NOT FIND him/her having the high propensity/likelihood of dropping out of school.
ADDITIONAL COMMENTS:__________________________________________________________________________
TRANSCRIPT REQUEST FORM
Attention School Administrator: (provide documentation of the following for this student) Transcript(s), Individualized Education Program, Special Education instruction, other
The Oregon National Guard Youth Challenge Program is designated as an Alternative School by the Oregon Department of Education and is accredited by the Commission on Schools of the Northwest Association of Schools and of Colleges and Universities. The following credits are offered: 1 Credit Math 1 Credit P.E./Health 1 Credit English/Literature/Composition 1 Credit Communication Arts: Social Studies/Science 1 Credit Life Skills/Careers 3 Credits Work Study If the above credits do not apply to this student, list the course titles and number of credits you wish this student to receive. A student may earn (8) or more High School Credits.
COURSE TITLE__________________________ COURSE TITLE__________________________ COURSE TITLE__________________________ COURSE TITLE__________________________
CREDITS____ CREDITS____ CREDITS____ CREDITS____
COURSE TITLE_______________________________ CREDITS________ COURSE TITLE_______________________________ CREDITS________ COURSE TITLE_______________________________ CREDITS________ COURSE TITLE_______________________________ CREDITS________
____________________________________ School Administrator (print)
_____________________ Title
___________________ Phone
_______________ Fax
School Administrator (signature)_____________________________________________ Date_______________________ Student (signature)_______________________________________________________ Date_______________________ Custodial (Legal) Parent/Guardian (print)_____________________________________ Custodial (Legal) Parent/Guardian (signature)_________________________________ Date_______________________
NOTE: Oregon Youth Challenge makes no guarantees, implied or otherwise that a cadet who graduates from Youth Challenge will be accepted back/re-enrolled in their previous high school as a result of attending Youth Challenge or earning the Oregon GED. This is a parent/student responsibility to verify in advance and prior to enrolling at Oregon Youth Challenge Program. Some school districts have refused to accept/re-enroll a student if they have earned a GED. END NOTE------------------------------------------------------------
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 20 OF 41
O.N.G.Y.C.P. UNDERSTANDING OF: LIMITED MEDICAL SERVICES This form must be signed and submitted with the required OYCP Physical Examination
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 21 OF 41
VERY IMPORTANT INFORMATION FOR CONSIDERATION - Limited
Medical Services/Entrance Criteria & Considerations The Oregon Youth Challenge Program is a school. The program has very limited medical services available to the participating student. Services are limited to emergency care or transport and a weekly sick call service intended to care for minor illnesses that a student might experience in the traditional school district system. We are unable to provide any “on going” treatment or care. We are unable to accept applications from individuals who will require on-going medical or dental care that originated prior to arrival at the program or develops while in the program and prevents full participation on a daily basis. Parents/Guardians are to take care of all medical/dental matters that will prevent participation or be a distraction during the program. Staff resources and transportation: not available to transport students to medical/dental appointments. Medical/dental care is to occur during the breaks when the students are home.
THE FOLLOWING CONDITIONS MAY PREVENT ENTRANCE INTO THE PROGRAM:
Extensive use of multiple medications necessary to treat multiple conditions on a daily basis. Current/previous injuries/surgeries that prevent everyday participation in all physical and mental CORE activities. Dental services; braces adjustments, broken teeth, cavities, abscess and mouth disorders that impact/prevent the ability for the applicant to participate without on site care or assistance. Dental Care/Service is not available. Conditions or medications that adversely react or have side effects impacted by the high intensity physical activity and seasonal weather conditions that compromise the safety, health and welfare to the student(s). Medications/ conditions that may react adversely to extreme summer heat, winter cold and altitude. History/current conditions requiring medical, psychological or psychotic intervention for suicide treatment, manic depression, anxiety etc. Mental Health Services are not available All conditions above must be disclosed at time of application. If it is learned after the applicant arrives at Youth Challenge that these conditions exist, the student will be dismissed from the program and sent home. Youth Challenge cannot and will not assume financial or personal liability/risk/injury for students that have previous medical, physical or mental histories that could/will be impacted by the rigorous activities of the program. Applicants must have a full service medical physical examination and
work up completed within 90 days of entrance by a licensed medical provider. All injuries, dental/medical conditions must be completed and the applicant free from additional required care prior to entrance into the program.
Students with dental or medical needs that require immediate “emergency” care, off site time away from the program or that prevent participation will be dismissed and sent home. They may re-apply for the next class.
(RE-APPLYING FOR THE NEXT CLASS IN NO WAY SHALL CONSTITUTE A GUARANTEE THAT THE APPLICANT WILL BE ACCEPTED) MEDICATIONS/MEDICAL CARE
All required prescription medications must be disclosed in advance during the application process. All potential side effects & limitations of required medications must be disclosed at time of application. A medical release, approval and signature must be provided by the doctor in advance stating: applicant can safely participate in extreme hot, cold and high altitude conditions while consuming required prescription/medication(s). Parents / guardians are entirely responsible for all prescription medications and re-fills during the program. The system to fill/refill prescriptions must be developed within the programs criteria prior to acceptance into the program. Parents/legal guardians are responsible for all required medical/dental/psychological care before, during and after participation in the Oregon Youth Challenge Program. Injuries/physical/medical changes or new medications required by the applicant after the physical examination must be disclosed prior to entry into the program in writing for purposes of review, safety, health and welfare.
PARENT/GUARDIAN ACKNOWLEDGEMENT AND SIGNATURE OF MEDICAL CONDITIONS:
By my signature below, I’m indicating that I have read the above medical/dental/mental health restrictions. I understand that medical services are strictly limited and I understand/agree that any dental/medical/mental health care that is required as described above, except during the scheduled breaks, shall result in my son/daughter being sent home to avoid liability, risk and ensure the safety of the applicant/student. The program shall not be responsible or incur costs for any care, service or monitoring of an injury, surgery, medical, dental or psychological condition that was present, originated, previously known/treated before, during or after entry into the Youth Challenge program. I understand and agree that I’m responsible for all medical/dental/mental health care of my child during, before and after participation in OYCP.
Legal Guardian must be the legal custodial parent/state legal guardian assigned by the courts. -Required to provide proof-
Legal Guardian what is your relationship to the Applicant:
Son
Daughter
Legal Guardian
Other_____________
Legal Guardian (print) person authorized to sign the student into OYCP)_______________________________________ Legal Guardian (signature)_____________________________________________________ Date_________________ ----------------------Licensed Medical Provider: Review this document, sign and date at time of physical---------------------Licensed Medical Provider Address_______________________________________________Phone_____________________Fax________________ Medical Provider (name – print/type) Signature
PAGE 22 OF 41
MD
DO
PA
NP Date
O.N.G.Y.C.P. MEDICAL RELEASE CONSENT TO TREATMENT OF MINOR CHILD (to be completed by parties listed below)
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
I, the undersigned, do hereby authorize ANY PHYSICIAN, OREGON NATIONAL GUARD YOUTH CHALLENGE PROGRAM DIRECTOR and whomever he/she may designate as his/her staff to administer medical treatment as necessary to my son/daughter. Students Last Name_______________________ First Name______________________ MI___ Home Phone_________________ Work Phone__________________ Fax_______________ Cell ___________________ Mailing Address__________________________________ City_____________________ State____ Zip code_______ NOTE: I understand that my son/daughter will be cared for through my insurance if they become ill or injured. Insurance is required and if I do not have insurance I will apply (Oregon Health Plan 1-800-359-9517) or 24-hour School Insurance 1-800-767-0700 ext. 3 P.O. Box 809066, Dallas, TX 75380 (offered through Columbia Pacific Benefit Plans, Inc.) website: www.student-resources.net prior to my child registering.
(When applying for 24 hour Student Health Plan/Accidental School Insurance, clearly indicate: “BEND/LaPINE SCHOOL DISTRICT”)
(Proof of medical insurance is required) ALL medical costs are the parent/guardian responsibility. END NOTE-------------------------Name of Medical Insurance Provider_______________________________Subscriber____________________________ Name of Dental Insurance Provider____________________________________________________________________ Do you have a Co-Pay for prescriptions? Yes No ($ amount________________) Employer_____________________________________ Group #________________________I.D. # __________________ Responsible Custodial Parent/Guardian (print)_______________________________________Phone_________________ Name of emergency contact person (print)__________________________________________Phone__________________ Physician Name (print)________________________________Phone Number:_________________Fax:_______________
NOTE: I understand that I must provide my daughter/son with sufficient prescription medication during the program. Prescription medications may be supplied by
parent/guardian; refills may be called into the Bend, Oregon SAFEWAY Pharmacy Department. To set up the account call: 541-312-6486 (option #4) rd Fax: 541-312-6488 or write to: 642 NE 3 , Bend, Oregon 97701. OYCP staff are authorized to pickup prescription(s), medication(s) and refills at this Bend, Oregon Safeway. Kaiser does not have a facility here in Central Oregon and will not reimburse for any medical prescriptions. END NOTE-----------------------
Applicant: What medication(s) do you receive? List them below in the space provided.
MEDICATION _____________________________ _____________________________ _____________________________ _____________________________ DOSE/FREQUENCY _____________________________________ _____________________________________ _____________________________________ _____________________________________ REASON _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________
List medications you have received in the last 12 months________________________________________________ Drug allergies? Yes, What drugs?_____________________________________________________________ No Food allergies? Yes, What food(s)? Describe reaction to it: ________________________________________ No
List past injury(s), that may limit your ability to participate in daily strenuous physical conditioning:
(INJURY____________________________DATE___________)(INJURY__________________________DATE________) (INJURY____________________________DATE___________)(INJURY__________________________DATE________)
List current injury(s), that may limit your ability to participate in daily strenuous physical conditioning:
(INJURY____________________________DATE___________)(INJURY__________________________DATE________) (INJURY____________________________DATE___________)(INJURY__________________________DATE________)
-----------------------APPLICANT COMPLETE THE FOLLOWING BELOW: (MEMBERS LISTED AT BOTTOM OF PAGE SIGN AND DATE)--------------------YES NO Do you have asthma? YES NO Have you ever had a seizure? ATTENTION! YES NO Have you ever passed out with exercise? Participant may/will be subject to: YES NO Do you have any current skin itching/rashes? High altitude (3000 + feet) YES NO Do you have seasonal allergies requiring treatment? Adverse/Inclement weather YES NO Have you had a history of anxiety or panic attacks? Intense physical training and exercise to YES NO Have you ever had numbness/tingling in arms, hands, and legs? include running short/long distances over YES NO Have you ever had a head injury/concussion that required hospital stay? various terrain. YES NO Do you cough, wheeze and have trouble with breathing after exercise? Students receiving medications may/will YES NO Have you ever been knocked out, become unconscious, or lost your memory? experience side effects. The safety and YES NO Have you had a severe viral infection like myocarditis or mono in the last month? security of the student is paramount over YES NO Have you had a medical illness or injury since your last check up or sports physical? any/all scenarios. YES NO Has any family member/relative died of heart problem/sudden death before age 50? YES NO Has a physician ever denied/restricted your participation in sports for heart problems? YES NO Do you use special protective/corrective equipment/devices not usually used for your sport/position? (Examples: knee brace, retainer, hearing aide, etc.)____________________________________________________________________) YES NO Have you had vision/eye problems? When was your last eye exam?______________When was your last dental exam?______________ YES NO Do you wear glasses, contacts, eyewear?____________________________________________________________________________ YES NO Have you had a sprain, strain, swelling in muscles, tendons, bones, joints, or any other problems? If YES check the correct box below: Head elbow hip neck finger forearm thigh back wrist shoulder knee chest hand shin/calf upper arm Ankle finger foot OTHER____________________________________________________________________________________ YES NO Are you sexually active? Females only: Last menstrual period?____________ Days in cycle between periods?_______________ # of periods in last year?_____ YES NO Do you have problems with vaginal infections? YES NO Have you been treated for urinary tract infections? Applicant name (print)_____________________________________________ signature_______________________________ Date______________ Parent/Guardian name (print)_______________________________________ signature_______________________________ Date______________ Licensed Medical Provider Address_______________________________________________Phone_____________________Fax________________ Medical Provider (name-print/type) Signature
PAGE 23 OF 41
MD
DO
PA
NP Date
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
O.N.G.Y.C.P. PRE-PARTICIPATION PHYSICAL
To be completed by a Licensed Medical Provider. All other physical examinations are considered invalid for OYCP. It is recommended that the physical examination be conducted within a 90-day window before the program begins.
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 24 OF 41
Name_________________________________________ DOB_____________ Age_____ Today’s date_____________ Height________Weight______Pulse_________BP______/_______Vision R 20/____L 20/____ Corrected Yes No
INITIAL (BELOW) AND CHECK IF NORMAL (LIST ANY/ALL ABNORMALITIES) ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
ATTENTION!
Participant may/will be subject to: APPEARANCE______________________________________________________________________ High altitude (3000 + feet) Adverse/Inclement weather EYES/EARS/NOSE/THROAT ______________________________________________________________ Intense physical training and exercise to include running short/long distances over LYMPH NODES______________________________________________________________________ various terrain. Students receiving medications may/will HEART/LUNGS_______________________________________________________________________ experience side effects. The safety and security of the student is paramount over PULSES__________________________________________________________________________ any/all scenarios.
ABDOMAN_________________________________________________________________________ a As
parent/guardian of the student, prospective student and Licensed GENITALIA_________________________________________________________________________ Medical Provider it is requested that during this evaluation if anything is SKIN_____________________________________________________________________________ discovered that compromises the health, welfare and security of the student that it NECK/SHOULDER/BACK________________________________________________________________ noted and discussed immediately to all be parties involved. By recognizing and ARM/ELBOW/FOREARM_________________________________________________________________ addressing the issue at hand, corrective action can be taken as not to jeopardize WRIST/HAND________________________________________________________________________ health, welfare and security of the the prospective student. HIP/THIGH_____________________________________________________________________
LEG/KNEE_________________________________________________________________________________________________________ ANKLE/FOOT ________________________________________________________________________________________________________
______ HERNIA___________________________________________________________________________________________________________ NOTE: FEMALE APPLICANTS ARE REQUIRED TO PROVIDE WRITTEN PROOF OF A PREGNANCY TEST PRIOR TO ENTERING OYCP.
Lab tests for sexually active participants: FEMALES: Pap Smear___________ Gonorrhea__________ MALES: Gonorrhea__________ Chlamydia____________
Chlamydia____________ Pregnancy Test_________
Drug Allergies:________________________________________________________________________________________ Medical/Psych Diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________________
List previous surgeries and dates:___________________________________________________________________________
__________________________________________________________________________________________________
List Ortho FX/Injuries and dates:____________________________________________________________________________
__________________________________________________________________________________________________
Medications/Dosage and Frequency:_________________________________________________________________________
__________________________________________________________________________________________________
Discontinued medications within last 6 months:_________________________________________________________________ Comments:__________________________________________________________________________________________
__________________________________________________________________________________________________ Licensed Medical Provider (name - print/type)_______________________________________ Phone_________________ Address_____________________________________________________________________ Fax___________________
Licensed Medial Provider: At my level of professional experience/knowledge and based upon the final outcome/results of this evaluation
I CLEAR/FIND
I DO NOT CLEAR/FIND
this youth able to participate in any and all OYCP school activities.
Licensed Medical Provider (signature) MD DO PA NP O.N.G.Y.C.P. CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 25 OF 41
Date
APPLICANT’S DATE OF BIRTH (mm/dd/yyyy)________________ I, ___________________________________ (Applicant Last Name)
County___________________________________ ___________________ (MI)
_________________________________ (First Name)
authorize the State of Oregon, any other state, its counties, its cities and its agencies to submit and or exchange all pertinent information with the Oregon National Guard Youth Challenge Program regarding but not limited to the following: substance abuse history, referral history, court status, social, family, medical and any information as specifically requested by the Oregon National Guard Youth Challenge Program regarding the welfare and quality of life of the applicant mentioned above for the purpose of coordination of services. I understand that my records are protected under the Federal or State Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g., granted parole/probation, etc., contingent on this consent) and that in any event this consent expires automatically eighteen months (18) the date applicant’s official status is verified as “registered” by way of Oregon National Guard Youth Challenge Policy.
______________________________________ Custodial (Legal) Parent/Guardian name (print)
____________________________________ Custodial (Legal) Parent/Guardian (signature)
Executed this_____ of ________________________________, 200_____ ____________________________________ (Day) (Month) (Year) Applicant (signature) ------------------------APPLICANT: DO NOT WRITE BELOW THIS LINE IT IS FOR THE ADDRESSED/RECEIVING AGENCY ONLY-------------------------------
FROM: ADMISSIONS COUNSELOR, OREGON NATIONAL GUARD YOUTH CHALLENGE PROGRAM TO: AGENCY/AGENCY REPRESENTATIVE (AS SPECIFIED/INDICATED BELOW) SUBJ: REQUEST RELEASE OF CONFIDENTIAL INFORMATION Juvenile Department: Background check/face-sheet indicate disposition(s) Psychological Eval etc.______________________________ Department of Community Human Services: Verification of services rendered to applicant/family Employment Department: Verification of services rendered to applicant/family
Food Stamps
Cash Aid
Medical
All Services
Unemployment benefits
Other__________________________
Educational Institution: Transcript (current/latest) I.E.P. documentation Special Education documentation Behavioral Other___________________________________________________________________________________________ Medical:____________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Other:_____________________________________________________________________________________________
FROM: TO: SUBJ:
NOTE:
AGENCY/AGENCY REPRESENTATIVE (AS SPECIFIED/INDICATED ABOVE) ADMISSIONS COUNSELOR, OREGON NATIONAL GUARD YOUTH CHALLENGE PROGRAM (QUESTIONS/CONCERNS CALL: 541-317-9623 EXT. 223 – OR – FAX: 541-318-1180) REPLY/RESULTS OF REQUESTED RELEASE OF CONFIDENTIAL INFORMATION
All requests from the Oregon National Guard Youth Challenge Program are time sensitive. FAX any and all information regarding the above listed individual to O.N.G.Y.C.P. Admissions Counselor. See the above release of information. Your timely response is appreciated. END NOTE--------------------------------------------------------------------------------------------------------REPLYING AGENCY COMMENTS:___________________________________________________________________________
__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
DISCLAIMER AND REQUEST FOR NOTICE OF TRANSMISSION ERROR 1. This communication may contain confidential information, which is intended only for the individual or entity named on this cover sheet. 2. The recipient of this transmission is prohibited from reading, disseminating, copying or distributing the information unless the recipient is the intended recipient, or the agent or employee of the intended recipient who is responsible for delivering the message to the intended recipient. 3. If this document is transmitted in error, immediately notify the sender and destroy all transmitted material.
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 26 OF 41
SUBMIT COMPLETED APPLICATION TO THE ADDRESS LISTED BELOW FOR PROCESSING 23861 DODDS ROAD BEND, OREGON 97701 CERTIFICATION AND SIGNATURE I understand the questions on this application form and that my answers are true to the best of my knowledge. I understand Oregon National Guard Youth Challenge Program provides penalties for making false statements in order to obtain enrollment status. Furthermore, I understand that any verbal or written statement that is false, fraudulent or misleading that is contained in this application or attached materials, or made in the course of any related process, whether made by me or by others at my request, will result in rejection of my application, denial of enrollment, or dismissal from Oregon National Guard Youth Challenge Program and if discovered after enrollment, and under some circumstances, may result in prosecution for a crime. I understand that OYCP’s considerations include the safety and success of Candidates and Staff. I certify that all statements contained herein are true and complete whether made by others or me at my request. If I am accepted, I give my word that I will complete the program obeying all program policies, rules and regulations. I authorize the Oregon National Guard Youth Challenge Program, the State of Oregon, any and all state/s, counties, cities and agencies to submit and or exchange all pertinent information with the Oregon National Guard Youth Challenge Program to check any references (public or private), verify education information provided on this enrollment application and as disclosed throughout the application process. I authorize Oregon National Guard Youth Challenge Program to inquire, check and or investigate all appropriate records relating to the position for which I am applying. I acknowledge, to be considered; I, along with my parent(s)/guardians must attend a required orientation, submit to an enrollment drug test (if selected to be a student at OYCP), a criminal history background check and other specified procedures as indicated by the application process as a condition of enrollment. I release and hold harmless the State of Oregon and all providers of information from any liability as a result of furnishing and receiving any information related to the Oregon National Guard Youth Challenge Program candidate selection and placement process. Furthermore, I fully understand that there are risks associated with participation in the program. Activities that include these risks are not limited to the following: sports injuries, illness, accidents while traveling in vehicles or aircraft, (land, sea and air) injury while participating in community projects or any other activities deemed proper by the Director of the Program. I understand that OYCP is competitive, accommodating only 150 candidates each class. OYCP will select the candidate(s) most likely to succeed. OYCP is a “candidate selective program.” This means that I may apply by submitting an application and that it does not mean I have been accepted into the program. I understand the application must be complete, to include: two (2) mentor applications that I am personally responsible for recruiting, coordinating and submitting to OYCP to be matched with my enrollment application. I understand OYCP will review/screen my application to determine potential eligibility. I give full permission for OYCP to have son/daughter a) have his/her photo taken and/or to be interviewed for purposes of brochures, newsletter, media, slide presentations and other publications b) participate in off campus work, field trips, and other events that involve travel by land, sea and air. I agree to submit any and all documents that relate to a) divorce b) foster care c) adoption d) legal guardianship e) beneficiary of public assistance and any other documents OYCP may request in order to determine potential eligibility for my selection/enrollment. I agree to have but not limited to the following: all medical, dental and vision work completed prior to “selection” if selected to attend OYCP. It is duly noted; any interruptions or the inability to complete/participate in OYCP daily activities will result in discharge from the program. I understand, prior history of assault or sexual offenses may prohibit review of application and enrollment into OYCP. OYCP’s selection considerations include the safety and success of Candidates and Staff. I understand that I will inform OYCP of any and all changes of my/Parent(s)/(Legal) Guardian status during the 17½ month duration. Examples are: Change of address, phone number(s), marital status, medical status, etc. I have read and understand the Youth Challenge Program – Application/enrollment process and the Youth Challenge Program Rules and Regulations. I will not deliberately drop out of school to attempt to meet YCP’s school drop out status. I will allow my application to be reviewed/screened to determine potential eligibility, knowing that YCP is a “candidate selective program”. I agree to the conditions stated in this “Certification and Signature” section, and this section is enforceable, as I have signed below.
Applicant name (print)______________________________________ Signature________________________________________Date___________ Custodial (Legal) Parent/Guardian name (print) Signature Date
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 27 OF 41
OREGON NATIONAL GUARD
YOUTH CHALLENGE PROGRAM
23861 DODDS ROAD BEND, OREGON 97701 (541) 317-9623 FAX (541) 318-1180
MENTOR PROGRAM
These pages (22-31) are to be given to the first (1 ) of the two (2) persons that you have selected as your potential mentor.
APPLICATION BOOKLET #1 st
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 28 OF 41
OREGON NATIONAL GUARD YOUTH CHALLENGE PROGRAM MENTOR APPLICATION
TABLE OF CONTENTS
POST RESIDENTIAL PHASE INTRODUCTION……………….……………………………………24 GOALS and MENTOR PROGRAM OVERVIEW…………………………………………………….25 MENTOR APPLICATION……………………………………………………………………………….26-29 REFERENCE SHEET……………………………………………………………………………………30,31
Collection and use of information by the National Guard Bureau
For purposes of filing as a mentor disclosure of your Social Security Number for the Oregon National Guard Youth Challenge Program is mandatory and must be entered on the application you submit. Your Social Security Number will be used to process your application and for statistical purposes as set forth by the National Guard Bureau. Your Social Security Number is and will be kept confidential under the privacy act of 1974, Public Law 93-579. Your Social Security Number will be used to carry out required Law Enforcement Data Systems Checks (L.E.D.S.) as it is necessary for the mentoring aspect of the Oregon National Guard Youth Challenge Program. Furthermore, mandatory submission of information such as date of birth, drivers license and its expiration, sex, height, weight and race are what greatly assist during the background check. This narrows down of what could be a list of persons with the same name, character features and etc., allowing the Oregon National Guard Youth Challenge Program to focus its selection process of the prospective mentor at hand. No other agencies, parties or the like will have access to your Social Security Number.
HELPFUL HINTS: (EXCLUSIVE TO OYCP) The mentor and applicant must be the same gender. The mentor phase is a 17½-month commitment, make sure that parent(s)/guardian(s) of the student and the student agree. The mentor is not to be a relative, either by marriage or bloodline. God-parents are not to be mentors. Mentor is to be with in the same geographic proximity as the person they plan to mentor. After completing OYCP Residential Phase, the student and mentor are to have four (4) contacts per month equaling 1 Contact per week; of the four contacts per month, two (2) contacts at a minimum are required to be face to face. Each contact is to be approximately 1 hour in length. It makes it easier for the mentor and mentee if they are within reasonable geographic proximity of each other.
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 29 OF 41
WHY MENTORING?
OYCP mentor application (continued)
Young people want support. The majority of young people cite parents or other adults as the first source of advice regarding personal problems. There was a time when our society was made up of extended families and close communities. Aunts, uncles, cousins and family friends often served naturally as mentors. While families bear the primary obligation to care for their children and to help them become healthy contributing citizens, other institutions can help families acclimate to a rapidly changing world. A mentor can provide the nurturing, supportive adult relationship absent in the lives of many of our young people. Adolescents today are an increasingly isolated population. Changes in the structure of the family, community, neighborhood relationships and in workplace arrangements have deprived young people of the adult contacts that historically have been primary sources of socialization and support for development. Many young people lack nurturing and supportive primary adult relationships. A mentor can provide that role, and perhaps more importantly, teach and guide the young person to find others to fill that role as well. A mentor must be willing to make a specified commitment of time… and keep it! Life Issues In Which Mentoring Helps Teen pregnancy Dropout prevention Substance abuse Parenting skills Illiteracy Transition from welfare to work Employment preparedness Work or school adjustment Job retention Financial management/budgeting Educational and career goals Home ownership College preparation
MENTOR PROGRAM - POST RESIDENTIAL PHASE INTRODUCTION (OYCP mentor application continued)
The Oregon National Guard Youth Challenge Program consists of three distinct phases. The first is a 2 week Pre-Challenge Phase. Next is the 20 week Challenge Residential Phase. Both of these phases take place at the facility in Bend, Oregon. The third is the Post Residential Mentorship Phase. OYCP is always recruiting new mentors for its graduating Corpsmembers (Cadets). OYCP mentors are people ages 21 and over who volunteer at least one hour a week to a cadet that has successfully completed the 22 week Residential Phase. The mission of an OYCP Mentor is to identify the goals that the graduate has set during the Residential Phase and then to successfully assist the graduate in integrating those goals into real achievements. The mentor relationship begins in the 13th week of the Residential Phase. At that time there is a Mentor/Mentee Matching Ceremony in Bend, Oregon. From week 13 until the end of the 22 week Residential Phase, the mentor and the mentee correspond by way of letter writing. The mentorship phase involves weekly meetings between an OYCP graduate and a responsible adult volunteer mentor from their home community. Each mentor is screened and trained prior to meeting with the
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 30 OF 41
cadet. The mentor becomes a friend and advisor for the cadet. Mentors must be same gender as the cadet.
O.N.G.Y.C.P. GOALS REGARDING MENTORING
To seek and train responsible adults to mentor the Residential Phase graduates. Provide the mentors with support necessary for a successful mentoring relationship with the graduates. Assist in creating and maintaining an open network of communication between all parties, to address issues and concerns that may arise during the Mentorship Phase.
MENTOR PROGRAM OVERVIEW - THE PROGRAM (OYCP mentor application continued)
The Oregon National Guard Youth Challenge Program is a 17 ½ month program that offers school dropouts an opportunity to change their futures. The students will live and work in a controlled, military environment that encourages teamwork and personal growth. During this time they will work toward achieving their career or educational goals under the guidance of a volunteer mentor from their home community. These goals are also called the Life Plan. WHAT IS MENTORING? Mentoring is a one-to-one relationship over a prolonged period of time between a youth and an adult who provides consistent support, guidance and concrete help as the younger person goes through a difficult, challenging situation or period in life. The goal of mentoring is to help youths gain the skills and confidence to be responsible for their own futures. This includes, an increasing emphasis on academic and occupational skills. WHY ARE MENTORING PROGRAMS NEEDED? In a closely-knit family and neighborhood, children and adults alike could readily forge many kinds of supportive relationships. But today those opportunities are often missing. Many children no longer attend school in their own neighborhoods. Single-parent families are no longer the exception, and some families live in geographic or emotional isolation from relatives and neighbors. Young people today often lack skills to develop helpful social networks. TRAINING Mentors that are selected are required to attend a one-time Mentor Training in Bend, Oregon at the program facility: 23861 Dodds Road, Bend, Oregon. The workshop lasts approximately four hours, followed by a two-hour mentor/mentee match ceremony, for a total of six hours. WHO IS ELIGIBLE? Any adult 21 years of age or older and who is interested and committed to a young person’s success is eligible to apply. For the Oregon National Guard Youth Challenge Program, mentors are: 1) same gender as the student they wish to mentor 2) of same geographic location 3) to make four contacts per month at one contact per week, of these two are to be face-to-face 4) non-related to the person they wish to mentor (bloodline, marriage) 5) God-parents are not to be mentors Attributes of a mentor include maturity, integrity, leadership, commitment, availability and compatibility. HOW CAN ONE APPLY? A mentor application may be obtained by either visiting the website at www.oycp.com or calling
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 31 OF 41
541-317-9623 ext. 223, 225, 235 or 245. A criminal background check will be conducted on all mentor candidates prior to being matched to a student.
MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 32 OF 41
NAME OF THE STUDENT YOU WILL BE MENTORING:
(Print neatly – Last name, First name)
MENTOR INFORMATION (print neatly):
FOR OFFICIAL USE ONLY: Staff Recruited Background Check Interview Reference Check Screened Trained Match Pool
Complete
Last Name_____________________________ First Name ___________________________MI____ Suffix: Gender: Ethnicity:
Hispanic
Jr.
Sr. Male
I
II
III
IV
Miles from Corpsmember____________
Female Asian/Pacific Islander Single Widowed Black (not of Hispanic Origin) Widower
American Indian/Alaskan
Multiracial Other
White (not of Hispanic Origin)
Marital Status:
Divorced
Married
Date of Birth (mm-dd-yyyy)_____________ Age_______Social Security #________-______-________ Driver’s License #________________________ State______ Expires _____-_____-_____ Occupation:_________________________________ Employer______________________________ Employment Status: Full Time Part Time Retired Height_____________ Weight______________ Temporary Unemployed Volunteer
Home Phone____________________________ Work Phone______________________ Ext. _____ Email Address(s):__________________________________/_________________________________ Fax______________________ Cell Phone____________________ Pager_____________________ #1 Address___________________________________ Is this your mailing Address? City_______________________________ State_________ Zip Code_______________ #2 Address___________________________________ Is this your mailing Address? City_______________________________ State_________ Zip Code_______________ Yes No Yes No
County_____________________________ Are you related to this youth you wish to mentor?
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
Yes
No
PAGE 33 OF 41
MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 34 OF 41
NAME OF THE STUDENT YOU WILL BE MENTORING: ___________________________________ (Print neatly – Last name, First name) Employer Name ________________________________________ Yrs/Mos with Employer_________ Employer Address___________________________________________________________________ Street City State Zip Answer the following questions: A. Have you ever been convicted of a sex-related crime? Yes (specify the state in which it occurred) _____________________________________ No Did the crime involve force or minors? Yes No B. Have you ever been convicted of a crime involving violence, or the threat of violence? Yes (specify the state in which it occurred) _____________________________________
No
C. Have you ever been convicted of a crime involving activity in drugs and/or alcoholic beverages? Yes (specify the state in which it occurred)______________________________________ No D. Have you ever been convicted of a crime, other than a minor traffic violation? Yes No
E. Have you ever been arrested for a crime for which there has not been an acquittal, or a dismissal? Yes No (Please Print Neatly) Auto Insurance Agent_______________________________________________________________ Name Address Phone Insurance Company_________________________________________________________________ Name Policy Number List three (3) references (one may be a relative) 1. ________________________________________________________________________________ Name Address Home Phone ______________________ Work Phone_______________________
2. ________________________________________________________________________________ Name Address Home Phone_______________________ Work Phone_______________________
3. ________________________________________________________________________________ Name Address
Home Phone
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
Work Phone
PAGE 35 OF 41
MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR
NAME OF THE STUDENT YOU WILL BE MENTORING: __________________________________ (Print neatly – Last name, First name) Do you have a cultural, or ethnic preference of the graduate you would like to mentor? Yes (what is your preference)?________________________________________________ No
What is your occupational, educational and/or training background? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
What are your interests, skills and/or hobbies? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Do you have a personality preference regarding the type of graduate whom you would like to mentor? (example: athletic/intellectual) Yes (state your preference)_____________________________________________________ No
Do you speak more than one language? Yes (specify the language and the level of proficiency? Language:____________________________________Proficiency:___________________________ No May we adults leave a legacy in our communities that our young can live in.
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 36 OF 41
MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR
NAME OF THE STUDENT YOU WILL BE MENTORING: __________________________________ (Print neatly – Last name, First name)
STATEMENT OF CONFIDENTIALLY
Confidentially is the preservation of privileged information concerning the student, which is disclosed in a professional working relationship; the mentorship. Part of what you learn is necessary to provide services to the student but other information is shared within the development of a helping and trusting relationship. Therefore, most of the information that you gain about a student is confidential; in terms of the law, disclosure could make you legally liable, or the disclosure may violate the trust that the student has developed with you causing damage to your mentoring relationship. All records dealing with specific students must be treated as confidential. General information, policy statements, or statistical material that is not identified with any individual or family, is not classified as confidential. Before you begin your mentoring assignment, you should be aware of the laws and penalties of breaching confidentiality. Although the OYCP is liable for your action while you are within the scope of your authorized duty, giving information to an unauthorized person could be interpreted as not acting within the scope of duty, and the OYCP could refuse to support you in the event of legal action. Violation of the Oregon Revised Statutes regarding confidentiality of records is punishable upon conviction by a fine of not more than $1,000 or by imprisonment in the county jail for not more than 60 days, or both. ADVISORY: In order to process this application, the applicant must sign below. A check of references, and the applicant’s criminal history (L.E.D.S.) will be made by the OYCP, Law Enforcement Agencies, or the Oregon National Guard, to verify the responses on this application. The information listed on this document is used for background investigation only. OYCP does not discriminate on the basis of race, color, creed, sex or age. I hereby grant to the OYCP, Law Enforcement agencies, or the Oregon National Guard permission to check my references and civil or criminal records to verify any statement made on this form. My signature below certifies that I have read, and understood the material above. I understand my duty as a mentor/agent of the State, to abide by the laws and policies regarding the preservation of confidential information.
Applicant/Prospective Mentor printed name________________________________________________ Applicant/Prospective Mentor signature___________________________________________________ Date
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 37 OF 41
OREGON YOUTH CHALLENGE PROGRAM
Ray Lewallen Oregon Military Department – Office of Public Affairs P.O. Box 14350, Salem, OR 97309-5047
Mentor Reference Response
Prospective Mentor: This page is to be given to the first (1st) of the two (2) persons that are willing to be a reference point of contact for you. OYCP will call this contact as part of the application process. Your immediate response is greatly appreciated! Name of Cadet to be mentored______________________________________________________________ (Print Neatly – Last name, First name) ________ has applied for volunteer work with the Oregon Youth
(Prospective Mentor = the person who gave you this form)
ChalleNGe Program, which focuses on the needs of at-risk youth. He/she (prospective mentor) is being considered for a match with an at-risk youth in a one-to-one relationship. Help us learn whether this person is suited for this type of volunteer work. We would be grateful if you would answer the questions on this form as fully and carefully as you can. Information received will be kept in confidence. How long have you known the applicant?____________ In what way?________________________________ Does the Prospective Mentor/applicant have a good home relationship? Does he/she work well with others? Yes No Yes No Yes No
Does he/she have a tendency to over-commit him/herself (get to involved)? How would you rate him/her as far as the following are concerned?: Excellent Personal habits Character Morals Compassion for those in need Completes commitments Emotional stability Receives constructive criticism Health Good Average Poor
Unknown
Other Comments:__________________________________________________________________________ ________________________________________________________________________________________ Would you consider this person as a volunteer with an at-risk youth? (Explain) ________________________________________________________________________________________ ________________________________________________________________________________________
Name Print________________________________Signature____________________________Date_______
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 38 OF 41
Home Phone (
)
Work Phone (
)
If you need additional information, please call. (Use the back of this form if more room is needed.)
OREGON YOUTH CHALLENGE PROGRAM
Ray Lewallen Oregon Military Department – Office of Public Affairs P.O. Box 14350, Salem, OR 97309-5047
Mentor Reference Response
Prospective Mentor: This page is to be given to the second (2nd) of the two (2) persons that are willing to be a reference point of contact for you. OYCP will call this contact as part of the application process. Your immediate response is greatly appreciated! Name of Cadet to be mentored______________________________________________________________ (Print Neatly – Last name, First name) ________ has applied for volunteer work with the Oregon Youth
(Prospective Mentor = the person who gave you this form)
ChalleNGe Program, which focuses on the needs of at-risk youth. He/she (prospective mentor) is being considered for a match with an at-risk youth in a one-to-one relationship. Help us learn whether this person is suited for this type of volunteer work. We would be grateful if you would answer the questions on this form as fully and carefully as you can. Information received will be kept in confidence. How long have you known the applicant?____________ In what way?________________________________ Does the Prospective Mentor/applicant have a good home relationship? Does he/she work well with others? Yes No Yes No Yes No
Does he/she have a tendency to over-commit him/herself (get to involved)? How would you rate him/her as far as the following are concerned?: Excellent Personal habits Character Morals Compassion for those in need Completes commitments Emotional stability Receives constructive criticism Health Good Average Poor
Unknown
Other Comments:__________________________________________________________________________ ________________________________________________________________________________________ Would you consider this person as a volunteer with an at-risk youth? (Explain) ________________________________________________________________________________________ ________________________________________________________________________________________
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 39 OF 41
Name Print________________________________Signature____________________________Date_______ Home Phone ( ) Work Phone ( )
If you need additional information, please call. (Use the back of this form if more room is needed.)
OREGON NATIONAL GUARD
YOUTH CHALLENGE PROGRAM
23861 DODDS ROAD BEND, OREGON 97701 (541) 317-9623 FAX (541) 318-1180
MENTOR PROGRAM
These pages (32-41) are to be given to the second (2 ) of the two (2) persons that you have selected as your potential mentor.
APPLICATION BOOKLET #2 nd
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
PAGE 40 OF 41
OREGON NATIONAL GUARD YOUTH CHALLENGE PROGRAM MENTOR APPLICATION
TABLE OF CONTENTS
POST RESIDENTIAL PHASE INTRODUCTION……………….……………………………………34 GOALS and MENTOR PROGRAM OVERVIEW…………………………………………………….35 MENTOR APPLICATION……………………………………………………………………………….36-39 REFERENCE SHEET……………………………………………………………………………………40,41
Collection and use of information by the National Guard Bureau
For purposes of filing as a mentor disclosure of your Social Security Number for the Oregon National Guard Youth Challenge Program is mandatory and must be entered on the application you submit. Your Social Security Number will be used to process your application and for statistical purposes as set forth by the National Guard Bureau. Your Social Security Number is and will be kept confidential under the privacy act of 1974, Public Law 93-579. Your Social Security Number will be used to carry out required Law Enforcement Data Systems Checks (L.E.D.S.) as it is necessary for the mentoring aspect of the Oregon National Guard Youth Challenge Program. Furthermore, mandatory submission of information such as date of birth, drivers license and its expiration, sex, height, weight and race are what greatly assist during the background check. This narrows down of what could be a list of persons with the same name, character features and etc., allowing the Oregon National Guard Youth Challenge Program to focus its selection process of the prospective mentor at hand. No other agencies, parties or the like will have access to your Social Security Number.
HELPFUL HINTS: (EXCLUSIVE TO OYCP) The mentor and applicant must be the same gender. The mentor phase is a 17½-month commitment, make sure that parent(s)/guardian(s) of the student and the student agree. The mentor is not to be a relative, either by marriage or bloodline. God-parents are not to be
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 41 OF 41
mentors. Mentor is to be with in the same geographic proximity as the person they plan to mentor. After completing OYCP Residential Phase, the student and mentor are to have four (4) contacts per month equaling 1 Contact per week; of the four contacts per month, two (2) contacts at a minimum are required to be face to face. Each contact is to be approximately 1 hour in length. It makes it easier for the mentor and mentee if they are within reasonable geographic proximity of each other. WHY MENTORING?
OYCP mentor application (continued)
Young people want support. The majority of young people cite parents or other adults as the first source of advice regarding personal problems. There was a time when our society was made up of extended families and close communities. Aunts, uncles, cousins and family friends often served naturally as mentors. While families bear the primary obligation to care for their children and to help them become healthy contributing citizens, other institutions can help families acclimate to a rapidly changing world. A mentor can provide the nurturing, supportive adult relationship absent in the lives of many of our young people. Adolescents today are an increasingly isolated population. Changes in the structure of the family, community, neighborhood relationships and in workplace arrangements have deprived young people of the adult contacts that historically have been primary sources of socialization and support for development. Many young people lack nurturing and supportive primary adult relationships. A mentor can provide that role, and perhaps more importantly, teach and guide the young person to find others to fill that role as well. A mentor must be willing to make a specified commitment of time… and keep it! Life Issues In Which Mentoring Helps Teen pregnancy Dropout prevention Substance abuse Parenting skills Illiteracy Transition from welfare to work Employment preparedness Work or school adjustment Job retention Financial management/budgeting Educational and career goals Home ownership College preparation
MENTOR PROGRAM - POST RESIDENTIAL PHASE INTRODUCTION (OYCP mentor application continued)
The Oregon National Guard Youth Challenge Program consists of three distinct phases. The first is a 2 week Pre-Challenge Phase. Next is the 20 week Challenge Residential Phase. Both of these phases take place at the facility in Bend, Oregon. The third is the Post Residential Mentorship Phase. OYCP is always recruiting new mentors for its graduating Corpsmembers (Cadets). OYCP mentors are people ages 21 and over who volunteer at least one hour a week to a cadet that has successfully completed the 22 week Residential Phase. The mission of an OYCP Mentor is to identify the goals that the graduate has set during the Residential Phase and then to successfully assist the graduate in integrating those goals into real achievements.
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 42 OF 41
The mentor relationship begins in the 13th week of the Residential Phase. At that time there is a Mentor/Mentee Matching Ceremony in Bend, Oregon. From week 13 until the end of the 22 week Residential Phase, the mentor and the mentee correspond by way of letter writing. The mentorship phase involves weekly meetings between an OYCP graduate and a responsible adult volunteer mentor from their home community. Each mentor is screened and trained prior to meeting with the cadet. The mentor becomes a friend and advisor for the cadet. Mentors must be same gender as the cadet.
O.N.G.Y.C.P. GOALS REGARDING MENTORING
To seek and train responsible adults to mentor the Residential Phase graduates. Provide the mentors with support necessary for a successful mentoring relationship with the graduates. Assist in creating and maintaining an open network of communication between all parties, to address issues and concerns that may arise during the Mentorship Phase.
MENTOR PROGRAM OVERVIEW - THE PROGRAM (OYCP mentor application continued)
The Oregon National Guard Youth Challenge Program is a 17-½ month program that offers school dropouts an opportunity to change their futures. The students will live and work in a controlled, military environment that encourages teamwork and personal growth. During this time they will work toward achieving their career or educational goals under the guidance of a volunteer mentor from their home community. These goals are also called the Life Plan. WHAT IS MENTORING? Mentoring is a one-to-one relationship over a prolonged period of time between a youth and an adult who provides consistent support, guidance and concrete help as the younger person goes through a difficult, challenging situation or period in life. The goal of mentoring is to help youths gain the skills and confidence to be responsible for their own futures. This includes, an increasing emphasis on academic and occupational skills. WHY ARE MENTORING PROGRAMS NEEDED? In a closely-knit family and neighborhood, children and adults alike could readily forge many kinds of supportive relationships. But today those opportunities are often missing. Many children no longer attend school in their own neighborhoods. Single-parent families are no longer the exception, and some families live in geographic or emotional isolation from relatives and neighbors. Young people today often lack skills to develop helpful social networks. TRAINING Mentors that are selected are required to attend a one-time Mentor Training in Bend, Oregon at the program facility: 23861 Dodds Road, Bend, Oregon. The workshop lasts approximately four hours, followed by a two-hour mentor/mentee match ceremony, for a total of six hours. WHO IS ELIGIBLE? Any adult 21 years of age or older and who is interested and committed to a young person’s success is eligible to apply. For the Oregon National Guard Youth Challenge Program, mentors are: 1) same gender as the student they wish to mentor 2) of same geographic location 3) to make four contacts per month at one contact per week, of these two are to be face-to-face
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS PAGE 43 OF 41
4) non-related to the person they wish to mentor (bloodline, marriage) 5) God-parents are not to be mentors Attributes of a mentor include maturity, integrity, leadership, commitment, availability and compatibility. HOW CAN ONE APPLY? A mentor application may be obtained by either visiting the website at www.oycp.com or calling 541-317-9623 ext. 223, 225, 235 or 245. A criminal background check will be conducted on all mentor candidates prior to being matched to a student.
MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR
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NAME OF THE STUDENT YOU WILL BE MENTORING:
(Print neatly – Last name, First name)
MENTOR INFORMATION (print neatly):
FOR OFFICIAL USE ONLY: Staff Recruited Background Check Interview Reference Check Screened Trained Match Pool
Complete
Last Name_____________________________ First Name ___________________________MI____ Suffix: Gender: Ethnicity:
Hispanic
Jr.
Sr. Male
I
II
III
IV
Miles from Corpsmember____________
Female Asian/Pacific Islander Single Widowed Black (not of Hispanic Origin) Widower
American Indian/Alaskan
Multiracial Other
White (not of Hispanic Origin)
Marital Status:
Divorced
Married
Date of Birth (mm-dd-yyyy)_____________ Age_______Social Security #________-______-________ Driver’s License #________________________ State______ Expires _____-_____-_____ Occupation:_________________________________ Employer______________________________ Employment Status: Full Time Part Time Retired Height_____________ Weight______________ Temporary Unemployed Volunteer
Home Phone____________________________ Work Phone______________________ Ext. _____ Email Address(s):__________________________________/_________________________________ Fax______________________ Cell Phone____________________ Pager_____________________ #1 Address__________________________________ Is this your mailing Address? Yes No
City_______________________________ State_________ Zip Code_______________ #2 Address__________________________________ Is this your mailing Address? Yes No
City_______________________________ State_________ Zip Code_______________
County_____________________________ Are you related to this youth you wish to mentor?
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
Yes
No
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MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR
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NAME OF THE STUDENT YOU WILL BE MENTORING: ___________________________________ (Print neatly – Last name, First name) Employer Name ________________________________________ Yrs/Mos with Employer_________ Employer Address___________________________________________________________________ Street City State Zip Answer the following questions: F. Have you ever been convicted of a sex-related crime? Yes (specify the state in which it occurred) _____________________________________ No Did the crime involve force or minors? Yes No G. Have you ever been convicted of a crime involving violence, or the threat of violence? Yes (specify the state in which it occurred) _____________________________________
No
H. Have you ever been convicted of a crime involving activity in drugs and/or alcoholic beverages? Yes (specify the state in which it occurred)______________________________________ No I. Have you ever been convicted of a crime, other than a minor traffic violation? Yes No
J. Have you ever been arrested for a crime for which there has not been an acquittal, or a dismissal? Yes No (Please Print Neatly) Auto Insurance Agent_______________________________________________________________ Name Address Phone Insurance Company_________________________________________________________________ Name Policy Number List three (3) references (one may be a relative) 1. ________________________________________________________________________________ Name Address Home Phone ______________________ Work Phone_______________________
2. ________________________________________________________________________________ Name Address Home Phone_______________________ Work Phone_______________________
3. ________________________________________________________________________________ Name Address
Home Phone
ONGYCP 1818 – 11616 (REVISED 09/03 – CHANGE TWO 03/04) RECYCLE PRIOR VERSIONS
Work Phone
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MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR
NAME OF THE STUDENT YOU WILL BE MENTORING: __________________________________ (Print neatly – Last name, First name) Do you have a cultural, or ethnic preference of the graduate you would like to mentor? Yes (what is your preference)?________________________________________________ No
What is your occupational, educational and/or training background? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
What are your interests, skills and/or hobbies? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Do you have a personality preference regarding the type of graduate whom you would like to mentor? (example: athletic/intellectual) Yes (state your preference)_____________________________________________________ No
Do you speak more than one language? Yes (specify the language and the level of proficiency? Language:____________________________________Proficiency:___________________________ No May we adults leave a legacy in our communities that our young can live in.
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MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR
NAME OF THE STUDENT YOU WILL BE MENTORING: __________________________________ (Print neatly – Last name, First name)
STATEMENT OF CONFIDENTIALLY
Confidentially is the preservation of privileged information concerning the student, which is disclosed in a professional working relationship; the mentorship. Part of what you learn is necessary to provide services to the student but other information is shared within the development of a helping and trusting relationship. Therefore, most of the information that you gain about a student is confidential; in terms of the law, disclosure could make you legally liable, or the disclosure may violate the trust that the student has developed with you causing damage to your mentoring relationship. All records dealing with specific students must be treated as confidential. General information, policy statements, or statistical material that is not identified with any individual or family, is not classified as confidential. Before you begin your mentoring assignment, you should be aware of the laws and penalties of breaching confidentiality. Although the OYCP is liable for your action while you are within the scope of your authorized duty, giving information to an unauthorized person could be interpreted as not acting within the scope of duty, and the OYCP could refuse to support you in the event of legal action. Violation of the Oregon Revised Statutes regarding confidentiality of records is punishable upon conviction by a fine of not more than $1,000 or by imprisonment in the county jail for not more than 60 days, or both. ADVISORY: In order to process this application, the applicant must sign below. A check of references, and the applicant’s criminal history (L.E.D.S.) will be made by the OYCP, Law Enforcement Agencies, or the Oregon National Guard, to verify the responses on this application. The information listed on this document is used for background investigation only. OYCP does not discriminate on the basis of race, color, creed, sex or age. I hereby grant to the OYCP, Law Enforcement agencies, or the Oregon National Guard permission to check my references and civil or criminal records to verify any statement made on this form. My signature below certifies that I have read, and understood the material above. I understand my duty as a mentor/agent of the State, to abide by the laws and policies regarding the preservation of confidential information.
Applicant/Prospective Mentor printed name________________________________________________ Applicant/Prospective Mentor signature___________________________________________________ Date
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OREGON YOUTH CHALLENGE PROGRAM
Ray Lewallen Oregon Military Department – Office of Public Affairs P.O. Box 14350, Salem, OR 97309-5047
Mentor Reference Response
Prospective Mentor: This page is to be given to the first (1st) of the two (2) persons that are willing to be a reference point of contact for you. OYCP will call this contact as part of the application process. Your immediate response is greatly appreciated! Name of Cadet to be mentored______________________________________________________________ (Print Neatly – Last name, First name) ________ has applied for volunteer work with the Oregon Youth
(Prospective Mentor = the person who gave you this form)
ChalleNGe Program, which focuses on the needs of at-risk youth. He/she (prospective mentor) is being considered for a match with an at-risk youth in a one-to-one relationship. Help us learn whether this person is suited for this type of volunteer work. We would be grateful if you would answer the questions on this form as fully and carefully as you can. Information received will be kept in confidence. How long have you known the applicant?____________ In what way?________________________________ Does the Prospective Mentor/applicant have a good home relationship? Does he/she work well with others? Yes No Yes No Yes No
Does he/she have a tendency to over-commit him/herself (get to involved)? How would you rate him/her as far as the following are concerned?: Excellent Personal habits Character Morals Compassion for those in need Completes commitments Emotional stability Receives constructive criticism Health Good Average Poor
Unknown
Other Comments:__________________________________________________________________________ ________________________________________________________________________________________ Would you consider this person as a volunteer with an at-risk youth? (Explain) ________________________________________________________________________________________ ________________________________________________________________________________________
Name Print________________________________Signature____________________________Date_______
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Home Phone (
)
Work Phone (
)
If you need additional information, please call. (Use the back of this form if more room is needed.)
OREGON YOUTH CHALLENGE PROGRAM
Ray Lewallen Oregon Military Department – Office of Public Affairs P.O. Box 14350, Salem, OR 97309-5047
Mentor Reference Response
Prospective Mentor: This page is to be given to the second (2nd) of the two (2) persons that are willing to be a reference point of contact for you. OYCP will call this contact as part of the application process. Your immediate response is greatly appreciated! Name of Cadet to be mentored______________________________________________________________ (Print Neatly – Last name, First name) ________ has applied for volunteer work with the Oregon Youth
(Prospective Mentor = the person who gave you this form)
ChalleNGe Program, which focuses on the needs of at-risk youth. He/she (prospective mentor) is being considered for a match with an at-risk youth in a one-to-one relationship. Help us learn whether this person is suited for this type of volunteer work. We would be grateful if you would answer the questions on this form as fully and carefully as you can. Information received will be kept in confidence. How long have you known the applicant?____________ In what way?________________________________ Does the Prospective Mentor/applicant have a good home relationship? Does he/she work well with others? Yes No Yes No Yes No
Does he/she have a tendency to over-commit him/herself (get to involved)? How would you rate him/her as far as the following are concerned?: Excellent Personal habits Character Morals Compassion for those in need Completes commitments Emotional stability Receives constructive criticism Health Good Average Poor
Unknown
Other Comments:__________________________________________________________________________ ________________________________________________________________________________________ Would you consider this person as a volunteer with an at-risk youth? (Explain) ________________________________________________________________________________________ ________________________________________________________________________________________
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Name Print________________________________Signature____________________________Date_______ Home Phone ( ) Work Phone ( )
If you need additional information, please call. (Use the back of this form if more room is needed.)
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