Mentoring Program Application

The Mentoring Application

We are excited about your interest in mentoring. All of the Mentoring Programs will service youth ages 13-24 from a variety of backgrounds and settings. You can choose the mentoring program that connects best to your desire to mentor. Please review the following requirements before completing the application:
 Mentors must be at least 21 years of age and male.
 Willing to undergo a background check.
 Attend a mentor training class.
 Should be able to dedicate the program's specified hours per month to mentoring.

The mission and goals include improving academic achievement, self-esteem, social competence, and avoidance of high-risk behavior by providing a relationship with a caring adult who works to help them achieve their full potential.

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* 1. Full Name:

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* 2. Date of Birth

Date / Time

Date

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* 3. Gender

Male

Female

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* 4. City:

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* 5. Email:

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* 6. Preferred Contact Method

Home Phone

Mobile

Work Phone

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* 7. Phone Number

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* 8. Job Title

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* 9. Education Completed

High School

Some College

Associates Degree

Bachelor's Degree

Master's Degree

Doctorate Degree

Other

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* 10. What inspires you to become a mentor?

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* 11. What mentoring program are you interested in?

VOICES- Young girls aged 10-18 at risk of juvenile justice involvement

MBK/Each One of Us- For Young men ages 14-19 that attend Jack Yates High School

Youth C.A.N. -Young men involved in the juvenile justice system.

Refugee Youth Mentoring- For youth ages 15-24 who have not lived in the United States for more than 5 years.

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* 12. Mentors may connect with their mentees in various and creative ways. Do you have the technology available to engage in e-mentoring?

Yes

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* 13. Are you willing to allow the Mentoring department to conduct a background check on you, including fingerprints?

Yes

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* 14. I agree to participate in the mentoring program. I understand
that my mentee will meet with me monthly for program-specific hours. I also agree to contact
the Program Manager if there should be a problem or if I am unable to attend an activity and/or if I can’t
meet at our specified time. I agree to contact program staff immediately if any issues or concerns arise.

Yes

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* 15. I understand the need to maintain confidentiality regarding information that I might gain about students,
families, and staff as I volunteer in the schools. I also understand that I am not to discuss individual
student progress or behavior with anyone other than school personnel. I understand that if I violate school
confidentiality rules, I may be asked to terminate my volunteer service.

Yes

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* 16. If I am selected to be a mentor I understand that my commitment involves spending a regularly scheduled
time weekly at the assigned school with my mentee throughout one school year. As part of my participation in this program, I will communicate with the Mentoring program personnel on a regular basis.

Yes

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* 17. I understand that pursuant to Section 22.0835 of the Texas Education Code, as well as program requirements within the Mentoring Program, has requirements to conduct a criminal history review and reserves the right to receive and review any records maintained by any law enforcement agency.

Yes