Youth Success Mentoring Mentor Application

Youth Success Mentoring Mentor Application

Thank you for your interest in the Youth Success Mentoring (YSM) Program! We are currently accepting new mentor applications.
Mentor Availability Requirements and Contact Boundaries

To be eligible as a mentor, you must be available once a week for 30-60 minutes during school hours, Monday through Friday, between 7:30 AM and 3:45 PM (times vary depending on school district and school). Please note:All mentoring takes place on school grounds, during school hours, and under school supervision. Mentoring is not permitted before or after school hours. No contact is allowed outside of scheduled school mentoring sessions or official Youth Success Mentoring (YSM) events where YSM staff are present.
This application is open to both adult mentors and high school students enrolled in RSD or SVSD. Please complete the sections relevant to your situation, including questions regarding your employer, occupation, or school. We appreciate your interest in supporting student success through mentorship!
High School Mentors Only!

Please note: You will meet with your mentee for about 30–60 minutes, depending on your availability and the elementary school schedule. If you attend full time at CHS, RLC, MSHS, or TRS, you will mentor after your school day, usually between 2:30 PM and the end of the elementary school day at your mentee’s school. If you have a flexible schedule, such as Running Start, you may meet at other times during the day that fit your classes.
RecordTypeId
Name

First NameLast Name
Preferred Name
Email
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address if different then mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number, landline.Format: (000) 000-0000.
Birth Date

MonthDayYear
Date
Marital Status
Gender
Ethnicity
Primary Language
Fluent Conversational Secondary Language
Other Names That You Have Used? (maiden, nicknames, etc)
Education Level
Employer: If Retired, Enter "Retired"
Current Occupation: If Retired, List Previous Occupation
If Currently a Student, School Attending
If Currently a Student, What Grade?
Do You Have Children in RSD or SVSD?
Ages, grades & schools your children attend in RSD or SVSD?
Please list the days and time that you are available M-F between 7:30am-3:30pm to mentor.
Why do you feel you would be a good youth mentor?
Previous volunteer or work experience with youth?
What are your interests and hobbies
What service or community or social groups do you belong to?
Where did you hear about YSM, recruitment souce?
Emergency contact

First NameLast Name
Emergency contact number
Please enter a valid phone number.Format: (000) 000-0000.
1. Name of reference (not related to you)

First NameLast Name
Email of Reference
example@example.com
Phone # of reference
Please enter a valid phone number.Format: (000) 000-0000.
2. Name of reference (not related to you)

First NameLast Name
Email of Reference
example@example.com
Phone # of reference
Please enter a valid phone number.Format: (000) 000-0000.
3. Name of reference (not related to you)

First NameLast Name
Email of reference
example@example.com
Phone # of reference
Please enter a valid phone number.Format: (000) 000-0000.
Have you ever been convicted of a crime?
If YES, please explain:
If you have additional comments regarding your application information, please include them here:
I agree to allow Empower Youth Network to run a criminal background check on me if over 18. For HS mentors I agree to allow EYN to check iwth the school I attend. Further, I agree to adhere to all school policies for volunteers. (please initial)
Initial
I understand that YSM/EYN reserves the right to accept or decline a mentor based on fit with the program (please initial)
Initial
I understand that all Youth Success Mentoring relationships take place on the school campus during school hours or at school authorized activities or through activities facilitated by YSM ONLY. (please initial)
Initial
I understand that contact outside of the program in person, social media, online, phone, text, transportation of mentee is NOT ALLOWED (please initial)
Initial
Would you be comfortable working with a student of a different culture, race, sexual orientation (including gender expression & identity), and/or religious background? (yes, no and/or comment)
I understand that I am required to attend a mentor interview and a new mentor training prior to being matched with a student. (please initial)
Initial
I understand that I am required to fill out paperwork and be background checked by RSD or SVSD before being matched with a student. (please initial)
Initial
All the information in this application is accurate to the best of my knowledge. If you agree, sign your FULL NAME
Please upload a picture of the front of your driver’s license or school ID (under 18) to confirm identity below
Front of your driver's license or school ID (if under 18)

Cancelof
Should be Empty:

Youth Success Mentoring Mentor Application

Mentor Availability Requirements and Contact Boundaries

High School Mentors Only!

Please upload a picture of the front of your driver’s license or school ID (under 18) to confirm identity below