CISPAC Mentoring Application

CISPAC Mentoring Application
Personal Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Perferred Contact

EmailPhone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender
Ethnic Background
Previous Last Name (if any)

Media Permission
CISPAC celebrates student success and may schedule activities such as photos, videos and media interviews during the mentoring session for positive recognition of CISPAC, Pittsburgh Public Schools, United Way of Southwestern Pennsylvania and the Mentoring Partnership of Southwestern Pennsylvania.

However, written permission is required to have on file. Please check one of the statements below and sign your name
Type a question

I grant permission for CISPAC, Be A Middle School Mentor Program to use my name and/photograph for positive public relations purposes which may include newsletters, annual reports, the media and/or mentee/mentor photo dayI do not grant permission for CISPAC, Be A Middle School Mentor Program to use my name and/photograph for positive public relations purposes which may include newsletters, annual reports, the media and/or mentee/mentor photo day.
Signature

Clear
Date

MonthDayYear
Date
Date

MonthDayYear
Date

CISPAC Mentoring Standards of Conduct
Be A Middle School Mentor (BAMSM) is designed to connect Pittsburgh Public Middle Schools students with caring and positive adult who serve as mentors – providing students with support, direction, and encouragement to achieve their career and academic goals.

All BAMSM volunteers are asked to read, sign, and commit to the following:

Mentor Responsibilities
- Meet 45 minutes to one hour a week with mentee at their school

- Contact your site coordinator if you are not able to attend a session

- Keep all mentee information confidential, unless abuse or neglect is suspected; in that case, report concerns to your BAMSM site coordinator

BAMSM Guidelines
- All major decisions affecting mentees must be cleared by the school principal, BAMSM building champion and/or the mentee’s parent(s) or legal guardian(s)

- All communication between mentors and mentees via telephone, cellular (cell) phone, text messaging, social networking and other external devices or technologies is prohibited. The prohibition includes but is not limited to Facebook, Pintrest, Instagram, Foursquare, and Twitter. Any exceptions must be provided in writing and approved in advance by the school’s principal, BAMSM building champion, BAMSM site coordinator, and the mentee’s parent(s) or legal guardian(s) (all parties must agree).

- All BAMSM activities are school based and approved by the school during sixth grade

- Mentors may not transport mentees

- Mentors should minimize physical contact with mentees

- Interact with mentees in public areas with others present

- Avoid lending money to mentees

- Avoid giving gifts to mentees (unless your school principal, BAMSM building champion, and BAMSM site coordinator all agree on a group gift exchange)

- Treat principals, BAMSM building champions, BAMSM site coordinators, mentees, and all others with respect

- Realize you are a school visitor whose purpose is to give support to mentee

- Exhibit behavior supportive of all racial/ethnic groups and gender/sexual identities

- Consult with your BAMSM site coordinator if problems occur
Signature

Clear
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Should be Empty:

CISPAC Mentoring Application

Personal Information

Background Information

Emergency Contact Information

References

Media Permission

CISPAC Mentoring Standards of Conduct