Sample Volunteer Mentor Agreement Form (Excerpted from The ACCESS Mentor Training Manual. Used with permission from the Mentor Coordinator Network, Grand Rapids, Michigan.) Commitment I have been informed about the [name of your program] and wish to be a volunteer mentor. I promise to participate for the next [length of time of your program] and will uphold my part of the volunteer-client relationship. I understand this relationship is grounded in the hope for a meaningful friendship with the client. As a member of a volunteer team, I will help to be in contact with our client at least weekly in person or by phone for [length of time of your program] and recognize that the relationship may continue beyond that. I agree to make reports as are required by the program. Confidentiality I promise to maintain the dignity of the client with whom I am matched, including respect for the client’s privacy, property, family and friends. I will honor mutually agreed upon boundaries of time, location, information and physical contact. I will hold confidential, within the volunteer team and staff and referrals of the program, all matters discussed or issues addressed in our mentoring relationship, except in those cases where the client gives specific release of information permission. Disclosure I understand that the limits of confidentiality, however, include that by law I must immediately report to the appropriate civil authorities (through Volunteer Recruiter) any involvement that the client may have in regard to child abuse, confession of a felony (serious property or physical injury) offense, the intention to do bodily harm to another person, or the intention to commit suicide. Waiver I understand that I am personally responsible for fulfilling this agreement. I understand that any injury I might sustain is covered by my own insurance and that my volunteer involvement is covered by the Federal Volunteer Act. I agree to release and agree to hold harmless and indemnify [name of your organization and all partner organizations] and the collaborative agencies involved in the [name of your program] from any and all injuries, damages, costs and liability of any kind arising from the performance of this agreement and the provision of services to the client. This covenant shall bind my estate, successors, heirs and personal representatives. Signature: Date: Name: Phone: Volunteer Recruiter: Agency: | 
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