I want to become an Adult Tutor with LVCC! Complete Your Adult Tutor Registration Form Below, or Choose CPRT, or Volunteer. Click “Submit” several times(bottom of page) when done. WHICH TUTOR Adult TutorChildren and Parents Reading Together Tutoror Volunteer TRAINING REGISTRATION FIRST NAME * MIDDLE INITIAL LAST NAME * GENDER MaleFemale ADDRESS CITY STATE ZIP CODE HOME PHONE CELL EMERGENCY CONTACT EMERGENCY PHONE EMAIL* PLACE OF BIRTH DATE OF BIRTH RESIDENT Full-TimePart-Time MONTHS IN NAPLES (For Part Time Residents) FROM TO EDUCATION High School DiplomaSome CollegeUndergraduate DegreeGraduate DegreeOther Education FIRST LANGUAGE ADDITIONAL LANGUAGES CURRENT EMPLOYMENT STATUS Full TimePart TimeRetired OCCUPATION (Current / Former) HAVE YOU EVER BEEN CONVICTED YesNo TUTORING DAYS MONDAY MorningAfternoonEvening TUESDAY MorningAfternoonEvening WEDNESDAY MorningAfternoonEvening THURSDAY MorningAfternoonEvening FRIDAY MorningAfternoonEvening SATURDAY MorningAfternoonEvening SUNDAY MorningAfternoonEvening TUTORING TIMES (please specify the times are you available, for example: 8am-12pm or 4pm-6pm) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Do you have any special preference for tutoring? What geographic area would you prefer for tutoring? North NaplesGolden GateEast NaplesCentralLVCC Office Would you like to tutor A student one to oneA small group (4-5 students)Two students at the same timeTwo students separately Would you be willing to be a substitute tutor for LVCC classes? YesNo Are you interested in helping Literacy Volunteers in a role other than tutoring? If yes, please specify the role: AmbassadorSocial MediaFundraisingSpecial EventsWebsite/InternetMailingsMarketingSmall Group InstructorNewsletterWorkshop AssistanceOther How did you learn about Literacy Volunteers of Collier County? NewspaperFriend/FamilyPublic RelationsSpecial EventWebsiteOther Any groups/clubs you belong to? e.g. book clubs, tennis group Please give any additional information about yourself which may be pertinent to this role, including prior experience. CHARACTER REFERENCES Please provide LVCC with three character references. We will contact your references prior to matching you with a student. FIRST REFERENCE 1st Reference NAME: 1st Reference ADDRESS: 1st Reference PHONE: 1st Reference E-MAIL (optional): SECOND REFERENCE 2nd Reference NAME: 2nd Reference Address: 2nd Reference Phone: 2nd Reference E-Mail (optional): THIRD REFERENCE 3rd Reference NAME: 3rd Reference Address: 3rd Reference Phone: 3rd Reference E-Mail (optional): CONFIDENTIALITY 1.Never give out personal information about a tutor,student,or volunteer. 2.Refer any request of information relating to LVCC tutors, students, or volunteers to the appropriate staff. 3.Personal information about a tutor, student, or volunteer should only be shared on a need to know basis. As a tutor/student/volunteer for LVCC, I understand in the course of my service, I may learn information about students, tutors, volunteers, or staff which is confidential: e.g. finances, living arrangements. I understand all such information shall be treated as completely confidential even after I terminate my services with LVCC. I agree not to disclose any information of a personal and /or confidential nature to any person not authorized by LVCC to have such information, without specific consent of the individual to whom such information pertains. Failure to comply with this Confidentiality Agreement will result in release from affiliation with LVCC. INITIALS* TUTOR STATEMENT OF INTENT As a LVCC tutor, I agree to do my best to carry out the following tutor responsibilities: 1.Begin or schedule tutoring within a month after completion of training; 2.Donate a minimum of a year to tutoring; 3.Maintain confidentiality; 4.Respect students’ rights and understand their responsibilities; 5.Promptly complete and return quarterly tutor hours and student progress reports; When possible, attend in-service training workshops and roundtables, and if for some reason I am not going to be able to carry out my responsibilities as a LVCC tutor, I will let the LVCC Office know and I will return the materials that were distributed to me, so that other tutors can benefit from them. I have read and understand the responsibilities expected of me as a representative of LVCC. INITIALS* PERSONAL RELEASE AGREEMENT For good and valuable consideration, receipt of which is hereby acknowledged, I irrevocably grant to LVCC and its assigns, licensees and successors, the right to use my image and name in all forms and all media including composite or modified representations for all purposes, including advertising, trade or any commercial purposes throughout the world and in perpetuity. I waive the right to inspect or approve any versions of my image used for publication or the written copy that may be used in connection with said images. I release LVCC and its assigns, licensees and successors from any claims that may arise regarding the use of my image including any claims of defamation, invasion of privacy, or infringement of moral rights, and/or rights of publicity or copyright. LVCC is permitted, although not obligated, to include my name as a credit in connection with said image. LVCC is not obligated to utilize any of the rights granted by this Agreement. I have read and understand the terms of this Release and I am of the age of majority and am of sound mind. INITIALS* RELEASE OF LIABILITY FOR GOOD AND VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, the undersigned does hereby release LVCC, its licensees, successors, or assigns for any breach of said organization’s written or unwritten policies regarding performance of the undersigned’s duties as a literacy volunteer/tutor, or actions or activities made or performed by the undersigned while performing those duties as a literacy volunteer/tutor or ancillary thereto. It is the stated intention of the undersigned to fully RELEASE the Literacy Volunteers of Collier County to the fullest extent possible, from any and all liability which could arise as a result of the undersigned’s association with said organization, including but not limited to any legal actions, either criminal or civil, and agrees to indemnify and hold harmless the LVCC from any such liability. I have read and understand the terms of this Release and I am of the age of majority and am of sound mind. FIRST & LAST NAME * DATE* SIGNATURE* Your information will never be shared with any third party.