Application FOR Quality-Based MEMBERSHIP (2012)
Program Name ______
The above-named program submits this application to Mass Mentoring Partnership for membership. A member of MMP staff will contact you upon submission of the completed application.
Please check level of membership requested:
___Affiliate Member
An Affiliate Member is non-profit youth serving organization, mentoring program, service organization, faith-based organization, educational institution, cultural institution, institution of higher education, foundation, or other non-profit entity with a demonstrated commitment to youth mentoring as a direct service provider. An Affiliate Member program may access many benefits through Mass Mentoring Partnership, as described on the Membership Benefits chart, and may apply to become an Associate Partner Member at any time by meeting the minimum requirements. If you are applying to become an Affiliate Member, please skip any questions that are not applicable to your program.
___Associate Partner Member
An Associate Partner Member is a formal youth mentoring program or organization in operation for a minimum of twelve (12) months with adult to youth matches that have met for one cycle of the program’s designated minimum match duration. Associate Partner Members are either actively engaged in completing the program standards’ self-assessment or “On the Road to Membership” completing a work plan. Associate Partner Members may access many benefits through Mass Mentoring Partnership, as described on the Membership Benefits chart. Associate Partner Members must complete the self-assessment and the “On the Road to Membership” process within four months or return to the Affiliate Member level.
Partner Members of Mass Mentoring Partnership are formal youth mentoring programs or organizations that successfully completes the requirements of the program standards’ self- assessment and review process at the Associate Partner level.
Partner Members agree to (1) fulfill the obligations outlined in the Mass Mentoring Partnership Membership Agreement and (b) complete a biennial membership update.
GENERAL PROGRAM AND CONTACT INFORMATION
Parent Organization (if applicable):______
Year Founded: ______Federal ID # for 501C3 Status: ______
Street Address: ______
City/State/Zip Code: ______
Organization Main Phone: ______Web site: ______
Executive Director: ______
E-mail: ______Phone: ______
Mentoring Program Name: ______
Year Founded: ______Web site (if different from Parent Organization): ______
Mentoring Program Manager: ______Title: ______
Phone: E-mail: ______Fax: ______
Street Address: ______
City/State/Zip Code: ______
Name and Title of Individual to whom MMP will send volunteer referrals:
Year of first contact with MMP: ______# of Staff Positions ______(full time equivalents)
How did the organization/program hear about Mass Mentoring Partnership: (Please check all that apply)
______MMP Website ______Direct e-mail
______Referral from other organization ______Direct mail
______Referral from funder ______Other
______Event If other, please specify: ______
Program is an Ambassador of Mentoring host site Yes____ No____
PROGRAM OVERVIEW
Please describe your mentoring program below or attach a document that describes your program.
Program description:
______
______
______
Program description, including primary goals of the program:
______
______
______
Match Model
____ 1 to 1 (one adult to one young person)
____ Group (one adult to no more than four young people)
____ Team (a group of adults matched with a group of young people)
____ Cross-Age Peer Mentoring (older youth matched with younger youth)
Location where matches meet:
In the community, matches primarily meet on their own
School-based program, matches meet during school hours or after-school only
School-based program, not associated with the mentee’s school
After school program, not associated with the mentee’s school
Faith-based institution, matches may meet at the site or in the community
Residential facility program, matches meet at the residence or in the community
Community-based organization, but the matches primarily meet at the organization and not in the community on their own
Workplace, matches meet primarily at the mentor’s workplace, may leave the site on occasion
On-line mentoring program, matches meet primarily online but may meet in person on occasion
Service Area
____ Greater Boston ____ South Coast, Cape, and Islands
____ Central MA ____ North Shore and Merrimack Valley
____ Western MA
County:
____Barnstable ____Berkshire ____Bristol
____Dukes ____Essex ____Franklin
____Hampden ____Hampshire ____Middlesex
____Nantucket ____Norfolk ____Plymouth
____Suffolk ____Worcester
Recruitment Procedures
1. Please list the groups that you primarily recruit. ___Men ___Women ___Both
___College students ___Young professionals ___Retired Persons ___High School Students
___Corporations/business partnerships ___Your organization or program staff
Other___ Please specify ______
2. When do you conduct your recruitment? When is your busiest recruitment time?
___Year round ___Spring ___Summer ___Fall ____Winter Busiest time is: ______
Screening Procedures
1. Do potential mentors complete a written application? ___Yes ___No
2. Do you require a personal interview with potential mentors? ___Yes ___No
3. Do you conduct a CORI check for potential mentors? ___Yes ___No
4. Do you require at least two references from non-family members for potential mentors?
___Yes ___No
5. Do you require potential mentors to attend a pre-match training? ___Yes ___No
6. Do you have any additional procedures for screening potential mentors? If yes, please list
______
Match Information
1. In the last 12 full months, how many youth mentees were in mentoring relationships in your program: _____
2. As of today, how many youth mentees are in mentoring relationships in your program: _____
3. The mentor-to-youth ratio: ______mentor(s) to ______youth
4. Do you currently have a waiting list for your program? ____Yes ____No
If yes, how many are currently on the waiting list:
____ Mentees waiting for mentors ____ Males ____ Females
____ Mentors waiting for mentees ____ Males ____ Females
Mentee racial demographics for youth on waiting list: (please provide a numeric answer)
____African American ____Asian ____Latino(a) ____White, not Hispanic ____Other
Provide the number of youth on the waiting list for the following age groups
____Ages 6-9 ____Ages10-14 ____Ages15-19 ____Ages20-24
Mentor Information
1. Minimum age of mentor: ____
2. Mentor volunteer time commitment:
Hours Per week Hours Per month Minimum duration (for example, 9 months, 1 year)
3. Mentor description: Please describe the characteristics of desired mentors for your program.
______
______
4. Desired gender of mentors: ____ Male ____ Female ____ Either
5. Accepting volunteer referrals: ____ Yes ____ No
6. Current Mentors Information:
Active number of mentors:
____Male ____Female
Mentor racial demographics:
____African American ____Asian ____Latino(a) ____White, not Hispanic ____Other
Enter the number of mentors in your program BY AGE:
____Ages 14-17 ____Ages18-22 ____Ages 23-35 ____Ages36-49
____Ages 50-64 ____Ages 65+
7. Are mentors salaried employees of your program? ____Yes ____No
8. Current Mentors include (check all that apply)
______High School Students ______College Students ______Retired Persons
______Affinity Groups ______Corporate Partners ______Other
Mentee Information
1. Mentee age range:
2. Mentee grade level range:
3. Gender of youth served: Male Female Either
4. Racial Demographics:
____African American ____Asian ____Latino(a) ____White, not Hispanic ____Other
5. Population served: Please describe your target population (i.e. age, ethnicity, gender, school attended, foster care youth, youth from a particular religious group, pregnant or parenting youth, etc.).
______
6. Mentee eligibility requirements: Please describe any special qualities or characteristics of the youth served by your program.
______
______
Program Budget
What is the annual budget of your mentoring program based on your last fiscal year? (If your program is a component of a larger organization, provide annual budget for just your mentoring program rather than your organization as a whole.) The annual budget should include (1) expenses for payroll, administration, occupancy, materials, travel, events, etc. Do not include the value of time donated by mentors; and (2) in kind benefits, such as DONATED marketing, legal services, advertising space and match activities.
____Less than $50,000 ____$50,000 to less than $100,000
____$100,000 to less than $250,000 ____$250,000 to less than $500,000
____$500,000 to less than $750,000 ____$750,000 to less than $1 million
____More than $1 million
______
Signature - Mentoring Program Manager Date
______
Signature - Executive Director of Agency Date
Page 2 of 6