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NUECES COUNTY JUVENILE JUSTICE CENTER

APPLICATION for VOLUNTEER/MENTOR/INTERN

Please check one of the following boxes for the purpose of this application:

Volunteer Mentor Intern

PERSONAL INFORMATION:

NAME: ______________________________________________________________________

ADDRESS: ___________________________________________________________________

CITY & STATE: ____________________________________________ ZIP: _____________

BIRTH DATE: _________________________ PLACE of BIRTH: _____________________

SS#: ___________________________________ SEX: MALE FEMALE

DRIVER’S LICENSE STATE & NUMBER: _______________________________________

HOME PHONE #: ______________________ WORK PHONE #: ______________________

E-MAIL ADDRESS: ___________________________________________________________

EMERGENCY CONTACT: ________________________________________________


Name

________________________________________________
Relationship

________________________________________________
Phone No: Home/Cell Work

1
EMPLOYMENT:

EMPLOYER: ____________________________________ HOW LONG? _______________

EMPLOYER’S ADDRESS: _____________________________________________________

______________________________________________________________________________

JOB TITLE: __________________________________________________________________

EDUCATION:

High School (Year Graduated) __________ GED _________

Or Last Grade Completed ____________

College / Trade School: _________________________________________________________

Degree or No. of Years Completed: _______________________________________________

Language, Other Than English: __________________________________________________

Special interests, skills or hobbies: ________________________________________________

______________________________________________________________________________

Special Groups/ Affiliations you have participated in: _______________________________

______________________________________________________________________________

OTHER INFORMATION:

Reason for wanting to Volunteer or Mentor or Intern with the Juvenile Probation
Department:
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

How many hours a week are you able to offer? _____________________________________

What days and hours? __________________________________________________________

2
HISTORY:

Have you ever been arrested? YES NO


If Yes, When? _________________________________________________________________

What were the charges? ________________________________________________________

______________________________________________________________________________
Have you ever been on PROBATION OR PAROLE? YES NO

If Yes, When? ____________________________________

Are you currently or have you ever sought help and received counseling or treatment for
emotional problems? YES NO

If Yes, When? ____________________________________

REFERENCES:

List someone who has known you at least one year. Please do not list any family members.

1. ________________________________________________________________
Name
__________________________________ _______________________
Contact Phone Number Years Known
________________________________________________________________
Address City & State Zip
________________________________________________________________
Employer Occupation

2. ________________________________________________________________
Name
___________________________________ _______________________
Contact Phone Number Years Known
________________________________________________________________
Address City & State Zip
________________________________________________________________
Employer Occupation

3
RELEASE OF LIABILITY & PLEDGE
I do hereby give permission to the Nueces County Juvenile Department to investigate my
background and character. I fully understand that my employer and my references may be
contacted and that a criminal records check will be conducted by the appropriate law enforcement
agency. By submitting this application, I hereby release the Nueces County Juvenile Department
of all liability that might inadvertently result to my reputation, employment, or financial status as
a result of any contact by the Nueces County Juvenile Department with my employer, law
enforcement agencies or personal references.

I understand that if accepted as a Volunteer or Mentor or Intern (which ever may apply)
with the Nueces County Juvenile Department, I will be required to participate in the
orientation program, familiarize myself with the policies and procedures of the Nueces
County Juvenile Department, and will protect the confidentiality of all client rights. I also
agree to conduct myself in a dependable and responsible manner. I understand that my
services at Nueces County Juvenile Department may be terminated at any time.

_____________________________________________
Print Name

______________________________________________ ___________________
Signature Date

Please return to:

Nueces County Juvenile Department


2310 Gollihar Road
Corpus Christi, Texas 78415
(361) 855-7303