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PathMakers Program Application
Mentor Version

Thank you for being interested in the PathMakers program.  We look forward to learning more about you and your interest in the program.

By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging.

Phone Type
OK to leave messages?
OK to Text?
How did you hear about us?

Emergency Information

PathMaker Interest Information

The information you share will help us understand you better. Please be as detailed as you can. We will keep this information confidential.

Please let us know how you want to participate

Confidential Demographic Information

This information is helpful for our anonymous reporting to our funding sources and securing grant monies. 

Marital Status
Preferred Pronouns
Education
Are you in need of permanent housing?
Are you homeless?
What best describes your living situation?
Employment Status

We want to know how many people are impacted by our help, so we want to know how many people are in your household?

Household Income
Race Self-Identification: (Check all that apply):
Ethnicity Self-Identification: (Check all that apply):
Do you or anyone in your family receive?
Do you or anyone in your family receive subsidized:

Policies and Releases

Photo/Video/Media Release*

I hereby grant WE CAN, its successors and assigns and those acting under its authority, and those for whom it is acting, the absolute right, for as often as it may elect, to copyright and/or use and/or publish any media pictures/video/media of me or in which I may be included in whole or in part, or in conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made through any media for outreach, education, advertising, trade, or any other lawful purpose whatsoever.

I hereby waive any right that I may have to inspect and/or approve the finished product or the advertising copy that may be applied. I understand that under no circumstances shall I have any right to maintain any cause against WE CAN, or anyone else by virtue of the terms of this agreement, or anything done pursuant hereto.

Website Permission*

We like to list our individual volunteers on our website as a way of thanking them and recognizing the value they bring to WE CAN. With your permission, we would like to add your name to this list.

Anti-Harassment Policy*

It is WE CAN’s policy that all employees and volunteers should be able to enjoy a work atmosphere that is free from sexual harassment and other forms of discriminatory harassment based on race, color, gender identity, religion, sexual orientation, marital status, age, national origin, disability, genetic background, ancestry, active military or veteran status or any other protected category. 

​Sexual and other forms of discriminatory harassment of employees or volunteers by other employees, volunteers or participants of WE CAN occurring in the workplace or in other settings connected with their WE CAN involvement is unlawful and will not be tolerated. Further, any retaliation against an individual who has complained about discriminatory harassment or against individuals who cooperated with an investigation of a discriminatory harassment complaint is similarly unlawful and will not be tolerated. 

Because WE CAN takes allegations of harassment seriously, we will respond promptly to complaints of harassment and, where it is determined that such inappropriate conduct has occurred, we will act swiftly to eliminate the conduct. WE CAN will impose any and all corrective actions deemed necessary, including disciplinary action where appropriate.

WE CAN encourages any volunteer who feels that he or she is being harassed or has witnessed harassment to come forward without fear of reprisal. Your complaint should be made either verbally or in writing to the board president.

Volunteer and Staff Confidentiality Statement and Agreement

In your work with WE CAN, you will be exposed to a range of confidential matters and information. Confidentiality is vital to WE CAN. There are three (3) main areas of confidentiality, which follow:

1. Participant information is confidential and is to be shared only among WE CAN staff, except in cases where there are legal considerations involved in the individual’s care. At no time shall the identity or specific situation of a participant be discussed inside or outside of WE CAN, except in a context relative to helping and supporting the individual. (Note: a participant of WE CAN is someone who receives any service from WE CAN).

2. Proprietary information of WE CAN is confidential and is not to be shared outside of the building. Proprietary information includes technical data, donor information, copyrights, and mailing lists (including participant, employee, and volunteer addresses and phone numbers). Please be aware that WE CAN owns proprietary information, and you cannot use it without express written permission of the Executive Director. 

3. Information shared by colleagues and/or coworkers, including participants who are volunteers or employees, must be afforded a certain level of discretion and respect for a person’s privacy. This includes any information shared by people with colleagues about their personal life or matters at WE CAN. 

4. All employees, volunteers, and consultants of WE CAN must agree to this confidentiality agreement. If you are unsure about the confidential nature of specific information, you should ask the Executive Director for clarification.

Substance Use Policy*

WE CAN requires that a participant be sober and not use alcohol or drugs on the day of a walk in, appointment, workshop or group. This is necessary for WE CAN to provide a safe space for our programming and events and to support women in recovery as well as women who have been impacted by loved ones who have or had a substance use disorder.

If a participant appears intoxicated or under the influence of drugs, WE CAN will ask the participant to leave the group, workshop, appointment etc and arrange a sober ride home (friend, family, taxi) with assistance from WE CAN.  If a participant leaves the premises while driving a vehicle and appearing intoxicated/under the influence of drugs, the WE CAN staff/intern/volunteer must call the police to notify them with the participant’s name and a description of the vehicle. 

WE CAN staff and volunteers reserve the right to call local Rescue at 911 if we have serious concerns about a participant’s health (including intoxication/under the influence of drugs) to ask Rescue to make an assessment.

COVID Policy

Do not come to the WE CAN office if you are not feeling well or are experiencing any symptoms associated with COVID-19, including fever, cough, sore throat, shortness of breath, loss of taste or smell, nasal congestion, or runny nose. Contact the WE CAN office to let us know, and stay home.

 

Anyone who begins to feel ill during the program should tell the WE CAN staff and leave the building. If unable to drive, their emergency contact will be notified.  If unable to drive, their emergency contact will be notified. 

Office protocols will continue to be updated on an as-needed basis, depending on evolving public health circumstances and guidance from the federal, state, and local government. These protocols may involve masks, distancing, or other precautions as needed. 

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