Creative Mentoring - Mentoring Application


	*Mentoring Application*

	We appreciate your interest in becoming a mentor. Mentors are concerned adults who commit their time, skills, and creativity to help young students achieve their potential through consistent one-to-one relationships. The information in this application will help us to match you with a student and will be kept confidential. *** An email copy of this form submission will be sent to the Home Email address entered below. This is a secure server (SSL)**
	Please be sure to fill in the fields with Red lettering and where the title has a Red background. The information in those fields are used for creating your Mentor Identification once your application has been submitted.

Mentoring Application

Name

First: M.I.: Last: Suffix:

Birth Date

/ / (Format: MM / DD/ YYYY)

Address 1

or P.O. Box

Address 2

or Apt

City

County

State

Zip

- (+ 4 not required)

Preferred Email

Home Phone

Cell Phone

SSN #

(Last four digits)

Gender

Race

If other Race, please specify

Employer Information

Employer

(Note: If your employer is not listed, select the "Other" option at the end of the list and enter the name in the text field below.)

Employer (Other)

Job Title/
Occupation

Length of Current Employment

Yr(s) Mo(s)

Address 1

or P.O. Box

Address 2

or Suite

City

County

State

Zip

- (+ 4 not required)

Work Phone

- May we call you at work?

Ext.

Fax #

Work Email

References

Please list the names, addresses and daytime telephone numbers of three (3) persons (non-family members) who have known you for at least three (3) years either personally or professionally.

Name

Phone

Alt Phone

Years Known

Relationship

Name

Phone

Alt Phone

Years Known

Relationship

Name

Phone

Alt Phone

Years Known

Relationship

Other Information

How did you hear about this mentoring program?

Referral Source Referral Name

If Other, please explain below:

Are you currently affiliated with any other mentoring programs?

Yes No If so, which program:

At which site do you wish to be a mentor?

1^st choice:

2^nd choice:

When are you available to mentor? (Check all that apply)

Morning

Monday Tuesday Wednesday Thursday Friday

Lunchtime

Monday Tuesday Wednesday Thursday Friday

Afternoon

Monday Tuesday Wednesday Thursday Friday

What grade level do you prefer?
(Check all that apply)
K - 2 3 - 5 6 - 8

In case of emergency, please contact:

Name: Phone: -

Please tell us about yourself. E.g.: Hobbies, Family, Interests, Volunteer activities ...

Have you ever mentored or worked with children before?
Please tell us about your experiences.

Please list any languages you speak other than English.

Have you ever been arrested? Yes No

Had any involvement with the police or courts? Yes No

If you answered Yes to either of the two previous questions, please explain:

Training Registration

Class Choice

See Training Schedule
Please click the Training Schedule hyperlink (above). Review the listing for the Date, Time, Location, Room, and Grade Level which best fits your schedule. Return to this page using the back button in the browser window, and choose the listing from the selection list below.

Training Id

Mentor Agreement

As a site-based Mentor, I agree to the following basic requirements:

To attend an approved training session before beginning to mentor.

To meet with my mentee for at least one hour each week, for at least the remainder of the current school year. (I understand that continuing this relationship beyond this school year is encouraged.)

To be on time for my scheduled mentoring sessions.

To notify the mentor coordinator or program personnel if I am unable to attend my regularly scheduled mentoring session.

To engage in the mentoring relationship with an open mind.

To ask for help and accept assistance from my mentee’s teachers, support staff, and mentor coordinator when necessary.

To keep discussions with my mentee confidential except where his/her safety and/or welfare may be in jeopardy.

To notify program personnel and the mentor coordinator of any changes in my employment, address, and/or telephone numbers.

To notify the mentor coordinator if I wish to change my assigned student or schedule.

To participate in the end-of-year evaluation process.

To notify program personnel and the mentor coordinator if I no longer wish to mentor.

To attend an approved training session once every two years to renew my mentor certification.

To meet with my mentee only on site or in a site-approved setting and only during regular site hours as stated in his/her parents’ permission form.

We appreciate your interest in becoming a mentor to a child. By submitting this application, you agree to the terms of the mentor agreement and attest to the truthfulness of all information listed on this application. You agree to let our program confirm all information listed and to conduct a federal and/or state criminal records check.

Please type your name in the field below to verify that you agree with the mentor agreement:
*REQUIRED

Privacy and Security Statement

Creative Grandparenting, Inc.

Delaware Mentoring Council

Delaware Association of Nonprofit Agencies

The National Mentoring Partnership


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