Youth Success Mentoring Mentor Application
Thank you for your interest in the Youth Success Mentoring (YSM) Program! We are currently accepting new mentor applications for the 2025-26 school year.
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 3:30 PM. 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. 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!
RecordTypeId
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Name
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First Name
Last Name
Preferred Name
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physical Address if different then mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone Number
*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number, landline.
Birth Date
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-
Month
-
Day
Year
Date
Marital Status
Please Select
Single
Married
Divorced
Domestic Partnership
Separated
Widowed
Gender
*
Ethnicity
*
Primary Language
*
Fluent Conversational Secondary Language
Other Names That You Have Used? (maiden, nicknames, etc)
*
Education Level
Please Select
Less than high school
H.S Diploma or equivalent (GED)
High School
High School plus
Associates Degree
Bachelor Degree
Masters Degree
Professional Degree
Some College
Terminal Degree (PhD, JD, MD, etc)
Trade School
No Degree
Other
Employer: If Retired, Enter "Retired"
*
Current Occupation: If Retired, List Previous Occupation
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If Currently a Student, School Attending
If Currently a Student, What Grade?
Do You Have Children in RSD or SVSD?
*
Yes
No
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.
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Why do you feel you would be a good youth mentor?
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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 Name
Last Name
Emergency contact number
*
Please enter a valid phone number.
1. Name of reference (not related to you)
*
First Name
Last Name
Email of Reference
*
example@example.com
Phone # of reference
*
Please enter a valid phone number.
2. Name of reference (not related to you)
*
First Name
Last Name
Email of Reference
*
example@example.com
Phone # of reference
*
Please enter a valid phone number.
3. Name of reference (not related to you)
*
First Name
Last Name
Email of reference
*
example@example.com
Phone # of reference
*
Please enter a valid phone number.
Have you ever been convicted of a crime?
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Yes
No
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)
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Initial
I understand that YSM/EYN reserves the right to accept or decline a mentor based on fit with the program (please initial)
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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)
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Initial
I understand that contact outside of the program in person, social media, online, phone, text, transportation of mentee is NOT ALLOWED (please initial)
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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)
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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)
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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)
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Initial
All the information in this application is accurate to the best of my knowledge. If you agree, sign your FULL NAME
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