20/10 Student Mentor Application

20/10 Student Mentor Application

Complete this application to apply to be a student mentor. Please fill out the fields and complete the required agreement and review sections.
Name

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
APSU Email
example@example.com
Personal Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender
Race
Household Members
For each person, please list the name, sex, age and their relationship to you.
School Information

Please provide educational information for the past two years.
Major
Program Director Name
Program Director Title
Program Director Phone
Please enter a valid phone number.Format: (000) 000-0000.
Dates Attended - From

MonthDayYear
Date
Dates Attended - To

MonthDayYear
Date
Extracurricular Activities
Mentor Motivation, Experience, and Commitment
Why do you want to become a mentor?
Do you have any previous experience volunteering or working with youth? If so, please specify.
What qualities, skills, or other attributes do you feel you have that would benefit a youth? Please explain.
Can you commit to participate in the 20/10 Vision Mentorship Program for a maximum of one semester?
Are you available to meet with a child one hour per week and have contact at least once per week? Please explain any potential scheduling issues.
Describe your general health. Are you currently under a physician’s care or taking any medications? If so, please explain.
How would you describe yourself as a person?
How would your friends, family, and co-workers describe you?
Are you willing to communicate regularly and openly with program staff, provide weekly information regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program?
Are you willing to attend an initial mentor training session and in-service training sessions as needed?
Availability, Interests, and Mentor Fit
Most convenient times to meet with your mentee

Other
If Other, please describe your available times
Do you speak any languages other than English? If so, which languages?
Would you be willing to work with a child who has disabilities? If so, please specify which disabilities you would be willing to work with.
What are some things you would like to do with a mentee?
How and why did you choose your field?
What is one goal you have set for the future?
If you could learn something new, what would it be?
Choose all activities you are interested in.

Other
Describe other areas of strong interest.
APSU Student Confidentiality Agreement

As a student at Austin Peay State University working with the Montgomery County Juvenile Court, I hereby declare that I will keep the identities of all juveniles and all information pertaining to said juveniles confidential, regarding any information learned while working directly or indirectly with juveniles, staff, and judges at the MCJC. Further, I will keep in confidence any personal confidential information learned about another APSU student in the administration of the mentoring program.
Student Confidentiality Agreement - Print Name
Student Confidentiality Agreement - Signature
20/10 Vision Mentoring Program Review

As a mentor intending to be matched with a mentee through the 20/10 Vision Mentoring Program, I certify that I have read and agree to the 20/10 Vision Mentoring Policies outlined in this forms.
Program Agreement - Print Name
Program Agreement - Signature
Please verify that you are human
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20/10 Student Mentor Application

School Information

Mentor Motivation, Experience, and Commitment

Availability, Interests, and Mentor Fit

APSU Student Confidentiality Agreement

20/10 Vision Mentoring Program Review