Volunteer Mentor Application | Montgomery County Ohio College Promise

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 *