Making Mentoring Meaningful

Mentor Application

 

 

Name:_____________________________________D.O.B.____________________

 

Address:_______________________City/StateZipCode:_____________________

 

Home Phone:________________________Cell Phone:_______________________

 

Email Address:________________________________________________________

 

Occupation:_______________________Company:__________________________

 

Work Phone:______________________ May we contact you at work?     Y      N

 

Best time to contact you at home/work:__________________________________

 

Highest level of education completed:___________________________________

 

Marital Status:____________Spouse/Partner’s Name________________________

 

Children:____________Names and Ages:__________________________________

 

How did you hear about the mentoring program?___________________________

 

Have you ever been convicted of a crime?               YES                 NO

 

Are you currently on bail for a crime?                     YES                 NO

 

Have you been released on your own                      YES                 NO

recognizance for a crime?

 

Do you object to our checking your                         YES                 NO

background with DCFS or CANTS for

matters of public record?

 

 

_____________________________________             ___________________________

Applicant Signature                                                  Date Completed

 

 

 

 

-Services are provided in collaboration with the Youth Network Council and Chicago Youth Centers-

 

 

 

 

 

 

 

Making Mentoring Meaningful

Mentor References and Questionnaire

 

 

 

Name:__________________________________________________

 

 

Please list three unrelated references.  One must be work specific.

 

Name                                            Address                            Phone

 

Why would you like to be a mentor?____________________________________________

 

__________________________________________________________________________

 

 

Have you worked with children before? If so, please describe.______________________

 

__________________________________________________________________________

 

 

What activities or hobbies would you like to share with a child?____________________

 

__________________________________________________________________________

 

 

What are some of your strengths and talents?____________________________________

 

__________________________________________________________________________

 

Can you commit to maintaining weekly contact with your mentee for a year? (via phone, email or in person)                                                           YES                 NO

 

Can you commit to seeing your mentee at least twice a month for a year? (activities or outings should be at least 2 -3 hours in length)                              YES                 NO

 

Do you anticipate any changes in the next year that would interfere with your ability to meet your mentor responsibilities? (moving, a new job etc.)       YES                 NO

 

 

 

-Services are provided in collaboration with the Youth Network Council and Chicago Youth Centers-

 

Making Mentoring Meaningful

Mentor Preference Form

 

 

Name:_______________________________________          Date:__________________

 

(Please circle)

 

I would like to be matched to a:                  Boy                 Girl                 Either

 

 

Age range of mentee:             4 – 6                7 – 9                10 – 12             13 – 14

 

 

Are you open to being matched to an African American mentee?     Yes                    No        

 

            

Once matched, what activities would you like to share with a mentee?

 

Movies                        Computers                             Football                     Music

 

Arts & Crafts               Swimming                             Basketball                  Volleyball

 

Cooking                     Gardening                             Video Games               Dance

 

Amusement Parks       Homework Help                    Beach                         Museums

 

Bowling                          Cultural Activities                      Reading                         Festivals/Fairs 

Do you own or have access to a car?                        Yes                  No

 

Can you provide proof of auto insurance?                Yes                  No

 

If no, how do you get around the city?                    Bus/Train        Family             Friends                                                                  

If yes, are you willing to pick-up and                      Yes                  No

drop-off your mentee at his/her home

for scheduled outings?

 

Would you be willing to meet your mentee             Yes                  No

at the Elliott Donnelley Youth Center for

activities?

 

What day(s) and time(s) do you anticipate    ____________________________

meeting with your mentee?

                                                                  ____________________________     

 

 

 

-Services are provided in collaboration with the Youth Network Council and Chicago Youth Centers-