Volunteer Mentor Application

Identifying Information

Name *

First

Middle

Last

Gender *

Male
Female

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Additional Phone (optional)

Employer

Work Address *

Address Line 1

Address Line 2

City

State

Zip Code

Work Phone *

Email *

Emergency Contact Name *

Emergency Contact Phone Number *

Background Information

Race/Ethnicity *

Other (Specify)

Age Category *

21-30
31-45
46-60
61 and over

Are you married? *

Yes
No

Do you have children? *

Yes
No

Number of children

Sons and Daughters *

Sons
Daughters

Ages of Sons

Ages of Daughters

Career/Education Information

Current Job Title *

Previous Jobs *

Highest Educational Degree *

High School Graduate
Some College Courses
College Graduate
Other

Other Degrees

College Degree or Major

Clubs and Organizations *

Mentor Information

I am interested in becoming a mentor in the Montgomery County Ohio College Promise Program because (check all that apply): *

Someone mentored me as a child or adult and it is my turn to give back what received
I think I’d be a positive role model
I like children
I have the time to give
I overcame difficulties growing up and would like to help someone else
I think I have the personality and ability to be a good mentor
I believe in the value of mentoring

How comfortable would you be in counseling your mentee regarding his or her poor use of judgment? *

Very comfortable
Somewhat comfortable
Not comfortable

How comfortable would you be in counseling your mentee regarding drug or alcohol use? *

Very comfortable
Somewhat comfortable
Not comfortable

Please indicate how comfortable you would be talking to your mentee about the following subjects:

Being Responsible *

Very comfortable
Somewhat comfortable
Not comfortable

Goal Setting *

Very comfortable
Somewhat comfortable
Not comfortable

Time Management *

Very comfortable
Somewhat comfortable
Not comfortable

College Planning *

Very comfortable
Somewhat comfortable
Not comfortable

Career Planning *

Very comfortable
Somewhat comfortable
Not comfortable

Hobbies/Interests *

Very comfortable
Somewhat comfortable
Not comfortable

Personal Problems *

Very comfortable
Somewhat comfortable
Not comfortable

What experience or training do you have working with children? *

None
A little (please specify)
A lot (please Specify)

Describe Experience

Please indicate how comfortable you would be in handling the following potential problems:

Your mentee does not show up for scheduled meetings at school. *

Very comfortable
Somewhat comfortable
Not comfortable

Your mentee seems unresponsive to your attempts to build a relationship. *

Very comfortable
Somewhat comfortable
Not comfortable

Your mentee shares sensitive thoughts or information with you. *

Very comfortable
Somewhat comfortable
Not comfortable

In which school communities would you be willing to serve as a mentor? (Check all that apply) *

All Montgomery County School Communities
Specific School Communities

Select all that apply. *

Have you ever been arrested for, charged with, convicted of, or plead guilty or no contest to any criminal offense including felonies or misdemeanors (other than minor traffic violations)? *

No
Yes

Yes Explain

Is there anything else you would like us to know about you?

How did you hear about us?

Who referred you?

References

Please list 3 references. Include at least one family member, one personal friend, and, if applicable, one work reference.

Reference One

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Relationship *

Reference Two

Name *

First

Last

Address (copy)

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Relationship *

Reference Three

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Relationship *

Volunteer Mentor Policies and Procedures Acknowledgement

As a volunteer mentor with the Montgomery County Ohio College Promise Program, I agree that I will adhere to the following standards:

Agree checkbox 1 *

As a mentor I will always act in a manner that is in the best interest of my mentee.

Agree checkbox 2 *

I will be reliable and maintain a regular schedule, committing to the agreed upon times for the weekly school visit.

Agree checkbox 3 *

I will faithfully notify the School Liaison and the Montgomery County Ohio College Promise Program Office of cancellations and schedule changes.

Agree checkbox 4 *

I will work independently in the designated area allowing other school personnel to carry out their responsibilities without interruption.

Agree checkbox 5 *

I will meet with my mentee in an area where school staff can observe my mentee and me.

Agree checkbox 6 *

I will not arrange contact with my mentee off school property unless it is under the supervision of the Montgomery County Ohio College Promise Program.

Agree checkbox 7 *

I will not drive or transport my mentee or their family, with the exception of College Promise sponsored events and with the written permission of the parent/guardian.

Agree checkbox 8 *

I will maintain confidentiality.

Agree checkbox 9 *

I will attend a Montgomery County Ohio College Promise Program mentor training and orientation session.

Agree checkbox 10 *

I will submit to Criminal Background checks as requested by the Montgomery County Ohio College Promise Program.

Agree checkbox 11 *

I will notify the Montgomery County Ohio College Promise Program office if I must terminate my mentor position for any reason.

Agreement *

As a Montgomery County Ohio College Promise Program Mentor I understand that I am offering my mentoring services to the Montgomery County Ohio College Promise Program without compensation and without any rights to health benefits in case of injury. I hereby give my permission for the Montgomery County Ohio College Promise Program to perform a criminal background check so that I may be eligible to become a mentor and work in school buildings with my mentee. I give permission for the Montgomery County Ohio College Promise Program to release my application and criminal background check information as requested to the school buildings/districts that I might be assigned to.

Declaration *

I declare that all of the statements made in this application are true, complete and correct to the best of my knowledge.

Name *

First

Last

Date *

Identifying Information

Background Information

Career/Education Information

Mentor Information

References

Volunteer Mentor Policies and Procedures Acknowledgement

The Montgomery County Ohio College Promise Annual Campaign is underway. We greatly value your charitable contribution in 2024 to further our mission.

Help Our Students Thrive