Hours of Operation

Monday - Friday 8:00am - 9:00pm with the exception of Wednesday the clinic is open from 8:00am - 12:00pm, and 5:00pm - 9:00pm.

Saturday - 9:00am - 1:00pm

Patient Satisfaction Survey

Youth Mentoring Program

Information Release

I, , understand it will be necessary for Youth Mentoring Program to conduct a background check regarding my driving record, criminal history, personal references, and employment.

I authorize First Nations Community HealthSource to obtain any needed information regarding my driving record, legal/criminal history, character references, and employment from any state or federal agency, my employer, and personal references for the purposes of participating in a Mentoring program. Further, I provide permission for First Nations Community HealthSource to conduct the same investigation of my background in previous states in which I have resided.

Further, I understand that information about me will be anonymously (without my name) shared with a prospective mentee(s) and his/her parent(s)/guardian(s) to aid in determining a suitable match. Once a Mentor/Menteematch is determined, my identity and any other information known about me may be shared with the Menteeand parent/guardian to ensure and aid in facilitating a safe and successful match relationship.

Signature
Date
Full Name:
Street Address:
City: State: Zip:
Date of Birth:
Social Sec. #:  
Current Driver's License No: State:
Please list any other cities, states, and dates of residency during the past 10 years.
City To (m/year) State From (m/year)
Please return or mail this application and the items listed above to Youth Mentoring Program, First Nations Community HealthSource,5608 Zuni Rd SE, Albuquerque, NM 87108.