Reach & Rise® - Mentor Application Type of Group Interest One to One Mentoring Group Mentoring Both Mentor Information: First Name Last Name Gender Male Female Date of Birth Age Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Email Address Phone Number Do you have any felony convictions or misdemeanors? Yes No Have you ever abused or molested a child? Yes No Do you have a clean driving record? Yes No Why do you want to become a Mentor? Why do you think children “act out” or get in trouble? Why do you think youth are referred to mentoring programs? How do you think they would benefit from being in a mentoring group? Would you be a positive role model to a child? What qualities do you have that will help mentor a child? Do you have any experience working with, volunteering, or spending time with youth? If yes, explain: Do you have any academic pursuits/experience that is related to working with youth? If yes, explain: Who was a mentor for you as a child? What qualities did they have that helped you? What’s your comfort level with leading a group of youth? Do you have any experience being a part of a group or team? Give example: Please describe any other volunteer experiences you have: Please describe your relationships with your family (e.g. parent(s)/guardian(s), siblings, etc.) both past & present. Include how you were disciplined as a youth and by whom. Please describe your relationship with a best friend and/or significant other? What are some of your interests & hobbies (things you would like to do with your mentee(s))? Do you have a preference as to the age, race/ethnicity, gender, sexual orientation, special needs, religious beliefs, political affiliation, socioeconomic background, or geographic location of the youth you’d work with? References The YMCA checks references for all volunteers and the Reach & Rise® Mentoring Program requires 2 Personal References & 2 Professional References. The following information is required of all applicants. Personal Reference # 1 Personal Reference #1 Name Email Phone Relationship to you? How long have you known this person? Personal Reference # 2 Personal Reference #2 Name Email Phone Relationship to you? How long have you known this person? Professional Reference # 1 Professional Reference #1 Name Email Phone Relationship to you? How long have you known this person? Professional Reference # 2 Professional Reference #2 Name Email Phone Relationship to you? How long have you known this person? signature Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Leave this field blank
Reach & Rise® - Mentor Application Type of Group Interest One to One Mentoring Group Mentoring Both Mentor Information: First Name Last Name Gender Male Female Date of Birth Age Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Email Address Phone Number Do you have any felony convictions or misdemeanors? Yes No Have you ever abused or molested a child? Yes No Do you have a clean driving record? Yes No Why do you want to become a Mentor? Why do you think children “act out” or get in trouble? Why do you think youth are referred to mentoring programs? How do you think they would benefit from being in a mentoring group? Would you be a positive role model to a child? What qualities do you have that will help mentor a child? Do you have any experience working with, volunteering, or spending time with youth? If yes, explain: Do you have any academic pursuits/experience that is related to working with youth? If yes, explain: Who was a mentor for you as a child? What qualities did they have that helped you? What’s your comfort level with leading a group of youth? Do you have any experience being a part of a group or team? Give example: Please describe any other volunteer experiences you have: Please describe your relationships with your family (e.g. parent(s)/guardian(s), siblings, etc.) both past & present. Include how you were disciplined as a youth and by whom. Please describe your relationship with a best friend and/or significant other? What are some of your interests & hobbies (things you would like to do with your mentee(s))? Do you have a preference as to the age, race/ethnicity, gender, sexual orientation, special needs, religious beliefs, political affiliation, socioeconomic background, or geographic location of the youth you’d work with? References The YMCA checks references for all volunteers and the Reach & Rise® Mentoring Program requires 2 Personal References & 2 Professional References. The following information is required of all applicants. Personal Reference # 1 Personal Reference #1 Name Email Phone Relationship to you? How long have you known this person? Personal Reference # 2 Personal Reference #2 Name Email Phone Relationship to you? How long have you known this person? Professional Reference # 1 Professional Reference #1 Name Email Phone Relationship to you? How long have you known this person? Professional Reference # 2 Professional Reference #2 Name Email Phone Relationship to you? How long have you known this person? signature Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Leave this field blank