URBAN YOUTH EMPOWERMENT NOW --- MENTOR APPLICATION

SECTION I: PERSONAL INFORMATION DATE: ______

Complete Section. Print Clearly in Ink or Type.

Social Security Number ______-______-______

Name ______

Last Middle First Suffix

Gender  Male  Female Date of Birth ______/______/______

month day year

Ethnicity (Please choose one)

 Alaskan Native or American Indian

 Asian or Pacific Islander

 Black, not of Hispanic origin

Address ______

StreetCityState Zip

Phone ______Email ______

Name/Address of Employer ______

______

Work Phone ______Occupation ______

SECTION II: EMPLOYMENT INFORMATION

Identify last two employers (not including current employer) in the space below.

Name of Employer / Title / Address and Phone / Years Employed

SECTION III: EDUCATION AND TRAINING

Identify your educational background (please choose one).

 Some High School

 High School Graduate

 Technical School

Is English the primary language you speak?  Yes  No

If NO, what is the primary language you speak: ______

Do you speak any languages other than English?  Yes  No

Identify language and level of proficiency ______

SECTION IV: VOLUNTEER INFORMATION
  1. Do you have previous experience as a mentor?  Yes  No

If YES, briefly describe your experience, responsibilities and thegroup with whom you worked.

______

______

______

______

  1. Do you have previous working with youth?  Yes  No

If YES, briefly describe your experience, responsibilities and thegroup with whom you worked.

______

______

______

______

  1. What days of the week are you available to volunteer? (check all that apply)

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
  1. What is the best time for you to volunteer? (check all that apply)

Morning / Afternoon / Evening

5. Initial the two statements below:

_____I understand that the mentor program involves spending a minimum of 4 hours a month attending bi-monthly meetings with assigned participants

_____I understand that I will be required to complete the mentor program orientation and at leasttwo training sessions during the year

  1. Write a brief statement (at least 500 words) explaining your interest in serving as a mentor in theUrban Youth Empowerment NOW program. Please address your background and the skills you can bring to the program.
  1.  Yes  No Within the past five years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, an offense of public indecency, or a violation involving a state/federally controlled substance?
  1.  Yes No Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in question #7?
  1. If the answer is YES to questions 7 or 8, please explain below:
SECTION V: REFERENCES AND CHECK

List the names, addresses and contact information of three people you would like to use as character references (please list only people you have known for at least a year).

Name: / Relationship:
Phone: / Email:
Address:
(include city, state and zip)
Name: / Relationship:
Phone: / Email:
Address:
(include city, state and zip)
Name: / Relationship:
Phone: / Email:
Address:
(include city, state and zip)

How did you hear about the program(please identify a source):

SECTION VI: INTERESTS AND PREFERENCES SURVEY

I prefer to mentor a: male female  no preference

I would like to start mentoring a participant:  As soon as possible

 Within the next 3 – 6 months

To what extent do you feel comfortable talking to others individually about the following?

Very / Somewhat / Slightly / Not at all
  1. Academic Skills

  1. College Planning

  1. Career Planning/Job Preparation

  1. Personal Issues

Hobbies, favorite recreational activities: Please check all that apply and specify further detail in the space provided
Sports and Physical Activities ______
Examples: Baseball, Basketball, Soccer, Football, Swimming, Tennis, etc.
Computers/Media ______
Examples: Computer Games, Computer Programs, Social Media, etc.
Social Activities ______
Examples: Cooking/Eating Out, Shopping, Movies, Traveling, etc.
Arts, Craft and Culture ______
Examples: Music, Poetry, Writing, Dancing, Attending Plays, Museums, etc.
Working/Entrepreneur ______
Education/Learning ______
Examples: Tutoring, Extending Learning, etc.
Other Activities ______

Identify any other areas of interest or information that would be useful in matching you with a participant (attach additional sheet if necessary).

______

SECTION VII: CERTIFICATION AND AUTHORIZATION

If you agree to become a mentor, you will be asked to agree to the following basic requirements. Please initial each statement:

______I understand and authorize the Urban Youth Empowerment NOW program 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 the program. ***I provide permission for UYEP NOW to conduct the same investigation of my background in previous states in which I have resided.***

______I understand that information about me, after acceptanceinto the Urban Youth Empowerment NOW program as a mentor, 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/mentee match is determined, my identity and any other information known about me may be shared with the mentee and parent/guardian to ensure and aid in facilitating a safe and successful match relationship.

______I acknowledge that during my volunteer service as a mentor through the Urban Youth Empowerment NOW program I will come in contact with propriety and confidential information regarding the program, and information pertaining to the youth that I am mentoring. I agree that I will not share or divulge any confidential and/or proprietary information regarding the Urban Youth Empowerment NOW program or the youth or families involved in the program while I am active in Urban Youth Empowerment NOW program and after I leave the program. I also understand there is no expiration date and therefore all confidential information will not be divulged regardless of my status in the Urban Youth Empowerment NOW program.

I certify to the best of my ability that the information provided on this application is true and accurate. I also understand that misinformation knowingly provided here, and on subsequent mentor application forms, is grounds for dismissal.

Privacy Act Statement

I understand that all forms and information obtained from me and about me will be held in confidence by the Urban League of Rochester. The Urban League of Rochester will not release, unless required by law, information from the volunteer file to outside sources without my written approval other than verification that I am a volunteer. I understand that certain information such as Name, Address and Employment may be released to the Mentee’s parents or affiliated Agency. In addition, periodically volunteer files are audited for the purpose of program evaluation by the National Office and the Urban League of Rochester, which will uphold the volunteer’s confidentiality.

______

Signature Date

Please return completed application
with a copy of your resume or CV to:

1 | UYEP NOW Mentor Application