Youth Challenge Academy Mentor Application

Youth Challenge Academy Mentor Application - Oahu
The Hawaii National Guard Youth Challenge Academy is very successful with its 16-18 year old youth in a non-traditional program. Eighty-three percent of the youths that volunteer for our quasi-military based 17-month program (5 months residential and 12 months post-residential) will receive their high school equivalency diploma. These youths would never have earned their diploma otherwise in a traditional school setting. We have made some astounding progress in redirecting their lives. We are very proud to say that most of our cadets who complete the program are now productive, respectable, and responsible citizens in our community.

We cannot do this alone; we need your assistance during the post-residential phase of the program. When our cadets return home after completion of the residential phase to pursue their future endeavors in employment, enlistment in a military service, or higher education, the values of self-discipline, motivation, respect, responsibility, focus, and determination learned at Youth Challenge can easily be lost when in the home environment. We need good role models, successful people like you, to make a difference by serving as a volunteer mentor. You are that caring adult outside of the family, who is willing to provide support, counsel, friendship, reinforcement and assistance.

Qualifications for being a mentor are:
- You must be drug free.
- 23 years of age or older and same gender.
- Have the ability to communicate and be willing to spend some quality time with your Cadet in finding out how he or she is doing and if they need assistance.
- You must be cleared by a police records check (no DUIs, felonies, sex crimes and alcohol or substance abuse within the last 5 years).
- We require two favorable character references.
- You CANNOT be an immediate family member (brother/brother-in-law/step-brother/half-brother, sister/sister-in-law/step-sister/half-sister or grandparents).
- You CANNOT be living in the same household.
- You are required to attend a Mentor Training Workshop.
We may not be able to resolve all the problems regarding our high school youths in Hawaii, but we sure can make a difference if we all work together as a team.

Help us, help the youths in our community, for a better community.

For more information, please call Mentor Coordinators Office

Gail Fujimoto Marivonne Mauga
Assistant Mentor Coordinator Assistant Mentor Coordinator
PH: (808) 685-7133 PH: (808) 685-7136
Email: gail.k.fujimoto@hawaii.gov Email: marivonne.t.mauga@hawaii.gov

Mentor Application Form
Name

First NameMiddle InitialLast Name
Gender
Date of Birth

MonthDayYear
Date
Marital Status
Address

Home/Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Business Phone
Cell Phone
Fax Phone
E-Mail
example@example.com
Employer
Occupation
Occupation Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation Status

Full TimePart Time
Do you have a driver's license?
Name of auto insurance company
Name of Applicant (Cadet) and relationship

MENTOR QUESTIONAIRE
Why do you want to become a mentor?
Where, or from whom, did you learn about the Youth ChalleNGe Academy?
Are you able and willing to commit to 12 months of follow-up with the Cadet while he or she is in the Post- Residential Phase?
Are you able and willing to commit to 12 months of follow-up with the Cadet while he or she is in the Post- Residential Phase?
Interests/Hobbies?
Special Skills?
Are you in the military?

YesNo
Rank
Unit
Duty description

REFERENCES

(NO immediate family)
Reference #1
Name
Relationship
Cell Phone
Home Phone
Work Phone
Reference #2
Name
Relationship
Cell Phone
Home Phone
Work Phone

SIGNATURE
This information is true and accurate to the best of my knowledge
Signature

Clear
Date

MonthDayYear
Date

MENTOR AUTHORIZATION TO RELEASE INFORMATION
I, Full name , hereby authorize the Youth Challenge Academy along with law
enforcement departments, to conduct whatever background search that may be deemed appropriate to assist
in determining my qualifications and suitability for the position I am seeking with the Youth Challenge Academy. I fully understand that the information you collect may be of sensitive, confidential, and privileged nature, and may reflect upon my suitability. I hereby release the Youth Challenge Academy and it’s agents from any liability and damage that may result from the exchange of requested information between law enforcement departments and the Youth Challenge Academy.
Full Name
Ethnic Group
Any Other Name Used/Aliases
Date of Birth

MonthDayYear
Date
Gender
Social Security Number
Length of time lived in this state
Other states you lived in
Signature

Clear
Date

MonthDayYear
Date

MENTOR LIABILITY RELEASE
I understand and agree that I will be the one actually spending time with my matched Cadet and that I must exercise care in supervising my Cadet while we are together. I also understand and agree that I am not a Youth Challenge agent, and that I am responsible for choosing and conducting all activities with my Cadet, and that Youth Challenge will not control how these activities are conducted except to ensure that they are done in the interest of the mentoring relationship. I therefore agree that Youth Challenge will not be liable for, and I agree to hold Youth Challenge harmless from any and all liability, causes of action and losses imposed on it in any way relating to or arising out of this mentoring agreement. I further release Youth Challenge from any and all liability, claims, demands, or actions or causes of action whatsoever arising out of any damage, loss or injury I might incur while participating in any of the activities contemplated by this mentoring agreement.
Signature

Clear
Date

MonthDayYear
Date
For more information, please call Mentor Coordinators Office @ 685-7133 or email: gail.k.fujimoto@hawaii.gov

POSITION DESCRIPTION – MENTOR
POSITION SUMMARY
The Mentor serves as a role model, friend, and advocate to a Cadet for at least fourteen months: 2 months in the residential phase and 12 months in the post-residential phase.
WORKING RELATIONSHIPS
Mentors report to Mentor Coordinator

Mentors supervises one Cadet
DUTIES AND RESPONSIBILITIES
- Commits in good faith to spending at least 14 months in consistent contact with a cadet.
- Cooperates with the mentor selection process by returning the mentor application and screening materials promptly.
- Attends the mandatory mentor training to learn how to relate effectively as a mentor to a cadet.
- Assists the cadet with the development and progress of his or her Post-Residential Action Plan.
- Makes consistent contact with the cadet by phone, mail, e-mail, FAX, or in person. Four contacts per month are required. At least two of them must be face-to-face during the post- residential phase.
- Observes all program policies and guidelines for mentors. Discusses violations of policies by cadet with the Mentor Coordinator.
- Refers the cadet to community resources as needed and helps the cadet obtain those resources.
- Participates in on-site visits and takes part in relevant activities.
- Shares occasional, informal, and fun activities with his or her cadet. The mentor and cadet will jointly select and schedule the activities.
- Communicates at least monthly by phone, FAX, or by e-mail with the Mentor Coordinator. The mentor will promptly inform the Coordinator of any problems, or needs in his or her cadet’s life, or in their relationship.
Signature

Clear
Date

MonthDayYear
Date
Mentor Name (Print)
Should be Empty:

Youth Challenge Academy Mentor Application - Oahu

Mentor Application Form

MENTOR QUESTIONAIRE

REFERENCES

Reference #1

Reference #2

SIGNATURE

MENTOR AUTHORIZATION TO RELEASE INFORMATION

MENTOR LIABILITY RELEASE

POSITION DESCRIPTION – MENTOR

POSITION SUMMARY

WORKING RELATIONSHIPS

DUTIES AND RESPONSIBILITIES