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SCHOOL TO WORK MENTOR APPLICATION

VIEWS: 10 PAGES: 5

									SONS OF ABRAHAM Mentoring Program
Mentor Application
Please complete the following application. All information you provide will be kept confidential.

Personal Information
Name: _________________________________________________                           Female         Male
          Last                  First             Middle

Home Address: ________________________________________________ Zip:_____________

Work Address:__________________________________________________________________
Telephone: Home: ___________________ Work: ____________________ Fax: _____________

           Cell phone: ___________________ E-mail: ________________________________
                                        Alt. E-mail:______________________________

Ethnic Background: (Please check the most appropriate) Optional:

   Caucasion     African-American            Native-American        Latino       Asian/Pacific Islander
  African Immigrant

   Other __________________________


Languages that you speak:          English       Spanish       Other(s) _______________________

Do you drive?      Yes       No

Do you own or have regular use of an automobile?            Yes      No

Name of Auto Insurance Co.: __________________________________


Commitment
Mentors are asked to spend 2 hours twice per month at working with the Sons of Abraham
program during interactive meetings with participants.

Are you willing to make this commitment?                                Yes       No

Does your schedule often cause you to be called out of town unexpectedly wherein you may
have to miss a scheduled mentoring session?                      Yes      No

Are their any other circumstances that might interfere with you keeping this commitment?
                                                                    Yes      No
If yes, please explain:

__________________________________________________________________


__________________________________________________________________

                Sons of Abraham Mentoring Program                                                         1
                Phone: 866.407.1532 Fax: 866.407.1532 e-mail: soa310@gmail.com
Work
Business you work for: __________________________________________


Position Title: ___________________________________________________


Name of Supervisor: ______________________________________________



Personality
I would characterize myself as (check any that apply to you):

    Quiet                 Talkative       Curious         Moody           Sensitive

    Shy                   Outgoing       Fun-loving       Cheerful        Spiritual

    Intelligent           Friendly      Confident         Stubborn        Thoughtful

Interests
Please circle any activities or subjects below that interest you:

Painting           Computers          Basketball      Roller–blading Tennis            Bicycling


Reading            Camping            Hiking          Cooking          Track           Volleyball


Music              Movies             Swimming        Baseball         Soccer          Wrestling


Football           Golf               Martial Arts     Dancing         Writing         Crafts


Woodcarving        Sewing             Collecting      Gardening        Electronics     Video Games


Chess              Billiards          Museums         Photography      Boxing          Checkers


Bowling            Fishing            Skating         Hockey           Jogging         Scuba Diving



Surfing            Other: ______________________            ______________________




                  Sons of Abraham Mentoring Program                                                   2
                  Phone: 866.407.1532 Fax: 866.407.1532 e-mail: soa310@gmail.com
Mentoring
Why do you want to be a mentor and what qualities do you have that would make you a good
mentor?

__________________________________________________________________


__________________________________________________________________


__________________________________________________________________

Please describe the characteristics you would like your mentee to have?

__________________________________________________________________


__________________________________________________________________


__________________________________________________________________


What prior experience have you had working with young people?

__________________________________________________________________


__________________________________________________________________


__________________________________________________________________

Are there any issues that you prefer not to deal with such as substance abuse, sexual orientation,
etc.?
If yes, please specifiy:

__________________________________________________________________


__________________________________________________________________


What educational experience have you had that would be helpful in being a mentor?

__________________________________________________________________


__________________________________________________________________


__________________________________________________________________

                Sons of Abraham Mentoring Program                                                3
               Phone: 866.407.1532 Fax: 866.407.1532 e-mail: soa310@gmail.com
During your lifetime so far, have you struggled with any problems that might parallel the
difficulties of the teens in the program?                   Yes     No
If yes, please explain:

__________________________________________________________________


__________________________________________________________________


__________________________________________________________________




SOA Positions
Please review the attached list of SOA positions. Please fill in two positions you are interested in.

1. ___________________________________

2. ___________________________________




                Sons of Abraham Mentoring Program                                                       4
               Phone: 866.407.1532 Fax: 866.407.1532 e-mail: soa310@gmail.com
          Sons of Abraham
          MENTOR AGREEMENT
As a mentor, I agree to the following:
1)   I will notify the program coordinator(s) if I cannot attend a scheduled session.

2)   I will participate in the mentor training session.

3)   I will help my mentee establish and achieve identified goals and plans.

4)   I will participate in special group events and activities.
5)   I will serve as a friend, coach, and listener for my mentee on personal, school,
     career, and other related issues.

6)   I will maintain confidentiality around issues related to my mentee, as long as
     what I am told is not going to harm my mentee or someone else.
7)   I will participate in the exit survey and other evaluation efforts of the project.

8)   I will participate in a screening process, which includes fingerprint clearance.

9)   I will not loan or give money, or buy extravagant gifts for my mentee, his/her
     friends or family.

By signing below, I attest to the truthfulness of all information listed on this
application. I agree to let Sons of Abraham Mentoring Program confirm all
information listed and to conduct a federal and state criminal records check, which
includes fingerprinting. I give my consent for Sons of Abraham Mentoring
Program to use my photograph and likeness in its releases & publications,
including its website. I agree to follow the rules of the program and be a dedicated
mentor.



____________________________________________                                  _____________
                              (mentor)                                            (date)




             Sons of Abraham Mentoring Program                                             5
             Phone: 866.407.1532 Fax: 866.407.1532 e-mail: soa310@gmail.com

								
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