Empowering Youth Mentor Program forms

Empowering Youth Mentor Program forms

These questions are designed to provide a comprehensive understanding of each applicant's needs, interests, and goals, ensuring that the program can effectively match mentors and mentees or address the needs of referred youth. Thank you for filling this form.
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Mentor Application Questions
Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
The following three questions are optional. They help us better understand and support the diverse identities of our participants, allowing us to create more meaningful mentor-mentee matches.
What is your race/ethnicity?
Gender Identity
Sexual Orientation
Tell us more about your occupation/profession and your educational background:
Why do you want to be a mentor?
Describe any previous experience volunteering, mentoring, or working with youth:
How would you describe your mentoring style (e.g., supportive, challenging, hands-on)?
How much time can you commit per week/month?
What do you hope to achieve by mentoring a youth in our program?
What do you hope your mentee gains from the mentoring experience?
Are there any specific areas you would like to focus on (e.g., academic support, career exploration, life skills)?
What are your hobbies and interests?
Any additional information you'd like us to know about you:
Please add 3 personal references below. (Please add their phone number, email address, relationship and how long you have known them)
Background Screening (this information will be kept confidential and secure)
Will you agree to have EYMP check your background through federal and state agencies for criminal records and child abuse and neglect proceedings?

YesNo
Do you have a valid Driver's License?

YesNo
State Issued
Date Issued

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
License Number
Have you ever been convicted of a crime? If Yes, please explain below:
Signature

Clear
Mentee Application Questions
Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
The following three questions are optional. They help us better understand and support the diverse identities of our participants, allowing us to create more meaningful mentor-mentee matches.
What is your race/ethnicity?
Gender Identity
Sexual Orientation
What is your current School/Grade Level and what school do you attend:
What are your Interests and Hobbies?
What are your goals for joining the program?
What are you looking for in a mentor?
How do you think a mentor can help you?
What are your preferred meeting times (after school, weekends, etc.)?
Is there anything specific you'd like to focus on, such as career advice, study tips, building confidence, or are you just looking to talk and enjoy some good company?
Have you had a mentor before?
How did you hear about the Empowering Youth Mentor Program?
What kind of person would you like your mentor to be? (A good listener, active in sports etc.)
What are three words that best describe you?
Please describe three things that you are good at:
Any additional information you'd like us to know about you:
Refer Youth to our Program Questions
Your Full Name (Parent/Guardian/person who is referring the youth):

First NameLast Name
Please provide your e-mail address
example@example.com
Phone Number
Please enter a valid phone number.
Please provide information for the Youth that you are referring
Name and Last Name of the Youth

First NameLast Name
Age of youth you are referring
The following three questions are optional. They help us better understand and support the diverse identities of our participants, allowing us to create more meaningful mentor-mentee matches.
What is youth's race/ethnicity?
Youth's Gender Identity
Youth's Sexual Orientation
Let's learn more about you and the Youth that you are referring
Your Relationship to Youth (Parent, Teacher, etc.):
Why are you referring this youth to our program?
Does the youth have any specific challenges or needs that a mentor could assist with?
What are the youth's strengths and interests?
Have you discussed this referral with the youth and their guardian?
Preferred contact information for the youth or guardian:
Any additional information we should know about the youth or their situation:
Signature

Clear
Should be Empty:

Empowering Youth Mentor Program forms

Mentor Application Questions

Background Screening (this information will be kept confidential and secure)

Mentee Application Questions

Refer Youth to our Program Questions

Please provide information for the Youth that you are referring

Let's learn more about you and the Youth that you are referring