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					                 A BETTER OREGON…ONE YOUTH AT A TIME
                                             OREGON NATIONAL GUARD
                                            YOUTH CHALLENGE PROGRAM
                                                23861 DODDS ROAD
                                               BEND, OREGON 97701
                                                PHONE: 541-317-9623
                                                 FAX: 541-388-9960
                                                 WWW.OYCP.COM


                                               APPLICATION

                    THE OREGON NATIONAL GUARD YOUTH CHALLENGE PROGRAM
                                 APPRECIATES YOUR INTEREST

                                                 ONGYCP’s MISSION
To provide opportunities for personal growth, self improvement and academic achievement among Oregon high school
drop outs, youth no longer attending, and those failing in school, through a highly structured non-traditional environment;
integrating training, mentoring and diverse educational activities.




            Class 40: Revised 2-26-10                                                                  Page 1 of 42
                ONGYCP TABLE OF CONTENTS / APPLICATION CHECKLIST
       (Please use applicants LEGAL name as listed on Birth Certificate or Court Document)
Pages (1–6): Oregon National Guard Youth Challenge Program Overview including the cover sheet and table of
contents. (Applicant and parent must read and understand; KEEP FOR YOUR RECORDS.)
Page (7): Mandated Eligibility Criteria Form (Must be signed by guardian, applicant and submitted)
Page (8): Certification of Drop Out Status; Applicant must be a school drop out prior to the program start date (Must be
signed by guardian, applicant and submitted)
Pages (9– 10): ONGYCP Physical; physical must be dated no earlier than July 15th, 2009
(Both pages must be signed by guardian, applicant, physician and submitted)
Page (11): Letter from Eye doctor stating eye examination results. Eye examination results dated within one year of
start date
Page (12): Letter from dentist stating there is no pending or ongoing dental work needed through December 2010.
Page (13): Insurance Information (Must be submitted)
Page (14): Applicant Contact Information (EMERGENCY CONTACT INFORMATION IS MANDATORY)
Page (15): Applicant Statistical Information (Must be submitted)
Page (16): What Will It Be Like At Youth Challenge? (Must be signed by guardian, applicant and submitted)
Page (17): Parent/Guardian Understanding/Agreement to Enroll Applicant (Must be signed by guardian,
applicant and submitted)
Pages (18 – 19): ONGYCP Participation Agreement (Must be signed by guardian, applicant and submitted)
Page (20-21): Family Education Rights and Privacy Act (FERPA) (Must be signed by guardian, applicant and
submitted)
Page (22): ONGYCP Consent for Release of Confidential Applicant Information (Must be signed by guardian,
applicant and submitted)
Page (23): ONGYCP Understanding of Limited Medical (Must be signed by applicant, guardian and submitted)
Page (24): Safeway Pharmacy in Bend (Must be signed by applicant, guardian and submitted)
Pages (25 - 26): Applicant Job History and Goals (Must be submitted)
Page (27 – 34): Mentor application Booklet #1 ____________________________
Pages (27 – 32): To be completed by the mentor and submitted by mail to ONGYCP (Must be signed and submitted)
Pages (33 – 34): Are forwarded by the prospective mentor to two (2) personal references of the mentor (Must be
signed and submitted)
Pages (35 – 42): Mentor application Booklet #2 ____________________________
Pages (35 – 40): To be completed by the mentor and submitted by mail to ONGYCP (Must be signed and submitted)
Pages (41 – 42): Are forwarded by the prospective mentor to two (2) personal references of the mentor (Must be
signed and submitted)
     SUBMIT CURRENT LEGIBLE COPIES OF: (each on a separate sheet of paper or accordingly)
School transcript(s): Dating back to the last time applicant attended school, alternative or other. Must show
cumulative GPA, total credits achieved and the total credits required to graduate.
Medical insurance policy card: Front and back clearly indicating you are insured.
Immunization/vaccination record: Current shot record
US Birth certificate, Proof of Permanent residency (I551) card.
Court generated/legal documents that may apply to you, your child/family circumstances: divorce/legal
guardianship/adoption/foster care/court order/etc. (These are required for proper communication/identification).
Medical Doctors written orders for special diet (if applicable)




        Class 40: Revised 2-26-10                                                                   Page 2 of 42
             NATIONAL GUARD BUREAU and THE STATE OF OREGON MANDATED ELIGIBILITY CRITERIA
1.   16 – 18 years of age at time of entry date into the program: Definition: If the applicant is 15 years of age or younger or is 19
     years of age on the day of program commencement, acceptance into the program is denied.
2.   A School Drop Out:
       a. A youth who is no longer attending any school and who has not received a secondary school diploma or a certificate from a
          program of equivalency for such diploma. Applicant has dropped out / withdrawn from school before the start of the
          program and must have Certification of drop out status (page 8) signed by parents/guardian.
     OR
       b. A youth having a high propensity/potential of dropping out of school due their academic standing.
             Must be withdrawn from school before the start of the program and must have Certification of drop out status (page 8)
              signed by parents/guardian.
3.   A citizen or legal resident of the United States AND a resident of Oregon for the last 6 consecutive months.
4.   Unemployed/Under Employed: Definition: An individual who is not regularly employed in full time work.
5.   Not currently on parole or probation, not awaiting sentencing, and not under indictment, accused, or have any open law
     violations. A prior history of assault/sexual offenses may prohibit enrollment into ONGYCP.
6.   Not currently or ever have been on parole/probation, incarcerated or convicted of a felony.
7.   Free from the use of illegal drugs or substances: Selected applicants will be tested – outcome is either pass/fail. Drug free
     means that an applicant must show no signs or indicators on the first day of Pre-Challenge of drug use as determined by a
     voluntary drug detection screen administered by the program.
8.   Physically/mentally capable to participate in ONGYCP: reasonable accommodations for physical/other disabilities must be
     arranged prior to in-process.
9.   Completed legible application on or before the ONGYCP deadline: The application needs to be for the next class beginning
     at ONGYCP. All signature pages must be signed. All miscellaneous documents requested by ONGYCP must be submitted for
     an application to be considered complete. The applicant must meet all eligibility criteria stated in the application.
10. Two (2) Mentor applications: For this program the mentor must: be an Oregon resident, be willing to commit for 14 months, be
    of the same gender as the applicant, be 21 years of age or older and live within the same geographic proximity (a distance that is
    not a travel burden to both the mentor/mentee), be able to pass a criminal history background check, and be able to complete a set
    of on-line mentor training modules prior to attending a required six-hour mentor training workshop/mentor match ceremony at the
    ONGYCP in Bend, Oregon. The mentor cannot be an immediate family member or anyone living in the same household as the
    applicant. All mentor training materials are written only in English.

                                                           INTRODUCTION

The Oregon National Guard Youth Challenge Program is an alternative School. It is a residential school where cadets (students) live
on site for 5 months while attending the military model school. This period is followed by a mandatory 12 month mentor phase back
in the community. Eligible individuals are accepted from all 36 counties in Oregon. The school is a non-traditional model that operates
similar to a military academy. The program is guided by military principles, structure and discipline. Our Staff utilize a "Hands off",
tough love, caring, and disciplined approach to instill values, train, and instruct cadets. Students are eligible to earn a high school
diploma, GED or credit recovery of 8 certified credits if they complete the required class work. The school is accredited by the
Northwest Association of Accredited Schools and is approved by the Oregon Department of Education.
The school is not easy...but it is rewarding.
 The target population of students are generally students who are considered "at risk", dropped out of high school, not attending school
or are failing in school. Students must be able and willing to participate in all 8 CORE components to graduate. A student who enrolls
must stay the entire 5 months and graduate to receive any credits, diploma or GED. It is all or nothing. To be eligible you must be a
high school dropout, 16 to 18 years old, and an Oregon resident. Applicants are required to have a minimum of two eligible mentors
prior to enrollment. You must be drug free at time of entrance and may not be on probation or parole at time of entrance. An
individual with a felony crime conviction is not eligible.

There are two phases to the program. The first phase is residential, which includes military structure, discipline, physical development,
service to community and academic classroom instruction. The second phase is a 12 month mentor active period when the student
returns to the community to implement goals, objectives, placement and post residential activities developed while in the residential
phase. All students must have a placement and responsible plan to implement back in the community to be eligible to graduate. Many
students earn their high school diploma, go on to community college, enlist in the military, return to high school, join the job corps,
start a job or similar vocational interest.
ONGYCP’s applicant selection include consideration of the safety and success of participant and Staff

              Class 40: Revised 2-26-10                                                                            Page 3 of 42
Applying for enrollment into the Oregon National Guard Youth Challenge Program is comparable to applying for work in
any private business or state agency. If the application is incomplete in anyway, or if the handwriting or documents are
not legible, your application will not be processed. Just like any job/position that one would apply for, the application
must clearly show qualifications or the potential eligibility for entry into that placement; ONGYCP is no different. The
application is the foundation of accountability, integrity and responsibility to support other ONGYCP components that
are actively practiced. The application must be complete (every question is to be answered). If a question(s) does not
apply, write “N/A or NONE” next to the question(s). When ONGYCP receives an enrollment application, it is only the
first phase of review it must go through for selection and placement into the program. Applying to ONGYCP does not
mean acceptance. ONGYCP is selective and will admit applicants that are most likely to succeed in this type of
program. Acceptance priorities shall consist of the following: 1) Applicant has been to an on-site mandatory
orientation (specific to the class for which you are applying) 2) Applicant meets the entrance criteria and has
submitted a completed application. Selection shall be extended to female applicants until 36 beds are filled and to male
applicants until 120 beds are filled. Priority consideration shall be given to 18 year olds, followed by 17 year olds and
then 16 year olds. In addition, the admissions unit shall consider applicants by geographic region that reflect the Oregon
High School drop out demographics of the state. Applications are approved/denied by the ONGYCP Selection
Committee. ONGYCP is a one-time second chance educational opportunity extended to an Oregon high school dropout.
                                        “ONGYCP is a privilege not a right”
JUSTIFIED REASONS FOR TERMINATION FROM THE PROGRAM:
“When does ONGYCP terminate a participant from the program?” Like many programs and schools, there are “values”,
rules, and expectations. In addition, ONGYCP is voluntary…your daughter/son can leave at any time voluntarily. We
will make every effort to help your child succeed. However, we reserve the right to send your child home and will
exercise that right if progress is not made according to our standards.
             THE FOLLOWING REASONS WILL TERMINATE PARTICIPANTS FROM ONGYCP
   Continuous disruptions and/or disorderly conduct that prevent teachers and staff from assisting your child and/or other
    participants in the program. We will not tolerate participants and parent(s) that disrupt the progress and growth of
    others. The Director will make this decision.
   There is zero tolerance for any drug/alcohol use or possession while in the program. All participants will take a
    required drug test after all passes, extended community visits, holiday school closures and randomly.
   At the discretion of the Director wherein staff/participant safety, program credibility, or heinous behaviors are
    unacceptable and outside the values of the Oregon National Guard and ONGYCP.
   A participant who walks away from any staff without authorization, or walks away from ONGYCP or any program
    sponsored activity.
   If a participant is not responding, complying, or making progress within the prescribed policies, procedures, rules or
    continually violates program requirements or presents ongoing behavior problems.
   In the event a participant no longer wants to participate or refuses to comply with program and staff requirements.
   Participants who are responsible for extensive and deliberate damage to our building or facilities will be dismissed
    and parents/guardian charged for the damage.
   Participants whose injuries and/or dental/medical issues interfere with or prohibit daily participation in all activities.
   Participants with mental health issues including depression, talk or threat of suicide, and psychological
    disorders/disruptions.
                                                      DRUG POLICY
ONGYCP uses a nationally approved portable test that is used by numerous treatment, corrections and juvenile system
programs. ONGYCP, at a minimum, tests for the following: Amphetamines, Alcohol (Ethanol), THC (Marijuana),
Cocaine (Benzoylecgonine), Opiates, Barbiturates and Benzodiazepines. Our interest is to administer the drug screen
objectively with the intentions of accepting all applicants. However, a positive result will automatically eliminate an
applicant from acceptance into the current class he/she applied for. Do not eat any foods that could/should/would show
up in the drug screen as a positive test. (Poppy seed muffins, certain breads, etc.) If you do, you will NOT enter the
program.
                                        WHAT ARE MY OPTIONS FOR A POSITIVE TEST?
You may seek an independent drug screen from a certified medical facility within twenty-four (24) hours. You must
provide original documentation of a negative drug screen result, dated and signed by an authorized medical official from a
testing facility and provide it to ONGYCP immediately within 24 hours. OR You may return home and apply for a future
class.

            Class 40: Revised 2-26-10                                                                     Page 4 of 42
                                                          ONGYCP’s GOAL

 Each participant in the program will continue in one or more of the following placements that equal full
 time (30hrs weekly) after graduating from ONGYCP.
 - Secondary Education (re-enter high school)        - Post Secondary Education (college)
 - Vocational Training                                                - Employment
 - Military                                                           - Volunteer Commitment

                                             ONGYCP EIGHT CORE COMPONENTS
                                              (Mandated by National Guard Bureau)

                                         LEADERSHIP/FOLLOWERSHIP
         Learn positive leadership responsibilities, followership responsibilities, and roles within social groups.
                                               RESPONSIBLE CITIZENSHIP
                     Understand civic responsibilities and the role of a positive citizen within the community.
                                            ACADEMIC EXCELLENCE
  Increase grade levels in reading and mathematics, attain a GED or high school diploma, and pursue higher education.
                                                          JOB SKILLS
                     Learn basic work skills; resume writing, job interview techniques, and career exploration.
                                            LIFE COPING SKILLS
 Learn personal financial management, teamwork skills, anger management, and drug and alcohol avoidance strategies.
                                                    HEALTH AND HYGIENE
                          Understand nutrition basics, substance abuse awareness, and personal relationships
                                               SERVICE TO COMMUNITY
                    Give back to the community by performing a minimum of 40 hours of community service.
                                                         PHYSICAL FITNESS
                             Improve personal fitness through daily exercise activities and intramural sports.

BENEFITS OF GRADUATING ONGYCP
1)   Military branches may consider ONGYCP graduates with a Diploma.
2)   Each graduate receives a letter of recommendation from the Director.
3)   Each graduate achieves academic and vocational experience to succeed.
4)   Each graduate achieves personal growth, self-esteem, and confidence.
5)   Graduates have the chance of successfully re-entering high school to achieve a Diploma.
6)   Participants may take the GED, or if they meet State Diploma Standards, earn a HS Diploma.




              Class 40: Revised 2-26-10                                                                          Page 5 of 42
                          GENERAL INSTRUCTIONS and APPLICATION SELECTION PROCESS
1. Obtain an application from: Oregon National Guard Youth Challenge Program (Web - www.OYCP.com) OR call
    (541) 317-9623 Ext. 223 OR write to: Oregon National Guard Youth Challenge Program, 23861 Dodds Road, Bend,
    OR 97701.
2. Verify that you meet eligibility criteria on page (7) of application. Call ONGYCP if further assistance is needed.
3. Attending an orientation at ONGYCP is mandatory. Parents/guardians and applicant must attend.
4. Complete and return the application to ONGYCP within 45 days from the date you attended orientation or December
    9th, whichever occurs first. The application will be screened to determine if the applicant meets eligibility
    requirements.
5. Your signature indicates that you agree to the conditions stated throughout the application and have completed
    necessary actions such as the certification of drop out status form of the application (page 8).
6. Submit current legible copies of ALL the following required documents:
     School Transcript(s): Dating back to the last time applicant attended school, alternative or other. Must show
         cumulative GPA, total credits achieved and the total credits required to graduate.
     Medical Insurance Card: Front and back clearly indicating applicant is insured.
     Immunization Record/Vaccination: Shot Record
     US Birth certificate, Proof of Permanent residency (I551) card.
     Court Generated/Legal Documents that may apply to you, your child/family circumstances. Example:
         divorce/legal guardianship/adoption/foster care/court order/etc.
7. Incomplete and/or illegible applications will not be accepted. ONGYCP is not responsible for applications that are
    misdirected, lost in the mail, or not received. It is highly recommended that you keep a copy of your application
    materials. ONGYCP will not provide copies.
8. Applications will go through a mandatory criminal background check (this process may take up to three weeks to
    complete).
9. MANDATORY: TWO (2) MENTOR APPLICATIONS (pages 27-42) – KEY PART OF YOUR SUCCESS!!!!
    Two separate prospective mentors must complete an application (one application per mentor). An applicant shall not
enter the program until ONGYCP receives two complete mentor applications.
    For ONGYCP the mentor must:
          Be an Oregon resident: Currently living in Oregon 12 consecutive months without any break in time.
          Be 21 years of age or older at the date of Mentor training.
          Be of the same gender as the applicant.
          Be willing to commit for 14 months.
          Live within the same geographic proximity (a distance that is not a travel burden to both the mentor/mentee).
          Pass a criminal history background check.
          Complete a set of mandatory on-line training modules.(Written only in English)
          Attend a six-hour mentor training workshop/mentor match ceremony at the ONGYCP in Bend, Oregon after
             the applicant begins the program.
          Not be an immediate family member or anyone living in the same household as the applicant.

    Furthermore, after the participant graduates the 5 month ONGYCP residential program in Bend, Oregon and returns
    to his/her respective community, the mentor and mentee must make four hours of contact per month; face to face
    being the preferred method of contact. Mentors may be anyone willing to commit and meet all ONGYCP
    requirements. Examples of mentors are: friends of the family, a neighbor, a local church congregation member,
    YMCA/YWCA Representative, Boys/Girls Club Representative, Big Brother/Sister Representative, Law Enforcement
    Representative, a Firefighter, or even a former Teacher to name just a few. To begin your quest, place emphasis on
    someone you already know. This will make the process easier. Without two (2) mentor applications, acceptance is
    denied.

INVITATION LETTER: Applicants that have submitted a completed application, have met program eligibility
requirements, and have been accepted will be mailed an invitation letter at a minimum of 14 days before the program start
date. The letter that one receives is exclusive. No one shall enter ONGYCP without receiving the invitation letter. It is
important to follow the detailed instructions in this letter; it will help answer questions that you may have.




            Class 40: Revised 2-26-10                                                                 Page 6 of 42
                                      MANDATED ELIGIBILITY CRITERIA FORM


  Yes   No Are you on parole/probation, awaiting sentencing, under indictment, accused, or have any open law
             violations?
  Yes   No Are you on or have you ever been on parole/probation, incarcerated or convicted of a felony?

  Yes   No Will you be 16 – 18 years of age at time of entry date into the program? Definition: If the applicant is
             15 years of age or younger or is 19 years of age on the day of program commencement, acceptance into the
             program is denied.
  Yes   No Are you a high school drop out? A general term that describes a youth who is no longer attending any
           school and who has not received a secondary school diploma or a certificate from a program of equivalency
           for such diploma.
  Yes   No Are you academically deficient? An individual having a high propensity/potential of dropping out of
           school due to an academic standing that would not allow the youth to graduate on time with his or her
           current class.
                 Must be withdrawn from school before the start of the program and must have Certification of drop
                   out status (page 8) signed by parents/guardian.
  Yes   No Are you a citizen or legal resident of the United States AND a resident of Oregon for the last 6
             consecutive months?
  Yes   No Are you Unemployed/Underemployed? Definition: An individual who is not regularly employed in full
             time work
  Yes   No Are you free from the use of illegal drugs or substances? Selected applicants will be tested – outcome is
             either pass/fail. Drug free means that an applicant must show no signs or indicators of drug use as
             determined by a drug detection screen administered by the program.
  Yes   No Are you physically/mentally capable to participate in ONGYCP? Reasonable accommodations for
             physical/other disabilities must be arranged prior to in-process.
  Yes   No Will you complete a legible application on or before the ONGYCP deadline? Only the most current
             application will be accepted. All signature pages must be signed. All miscellaneous documents requested
             by ONGYCP must be submitted for an application to be considered complete. The applicant must meet
             all eligibility criteria stated in the application. Those applicants with incomplete applications will be
             denied acceptance into the program.
  Yes   No Will you submit two (2) mentor applications? For this specific program the mentor must: be an Oregon
             resident, be willing to commit for 14 months, be of the same gender as the applicant, be 21 years of age or
             older and live within the same geographic proximity (a distance that is not a travel burden to both the
             mentor/mentee), be able to pass a criminal history background check, and be able to complete a set of on-
             line mentor training modules prior to attending a required six-hour mentor training workshop/mentor match
             ceremony at ONGYCP in Bend, Oregon after the applicant is enrolled in the program. Please note that all
             mentor training materials are available only in English. The mentor is not an immediate family member or
             anyone living in the same household as the applicant. Applicants with missing or incomplete mentor
             applications are subject to being denied acceptance into the program.
                                                     MENTOR INFORMATION
                                                      To be chosen by applicant
                      st
             My 1 choice mentor is: Last name _________________________ First name _______________________

             My 2nd choice mentor is: Last name _________________________ First name _______________________



Legal Guardian (Print) _______________________(Sign)___________________________Date__________________

Applicant (Print) ____________________________(Sign)__________________________Date__________________


          Class 40: Revised 2-26-10                                                                  Page 7 of 42
                                       CERTIFICATION OF DROPOUT STATUS
                                       PARENT MUST COMPLETE THIS FORM.

      The purpose of this form is to certify that the applicant is a high school dropout prior to the
       ONGYCP class start date. Oregon statute “ORS 339.505” defines a “high school dropout” as an
       individual who: (a) Has enrolled for the current school year, or was enrolled in the previous school
       year and did not attend during the current school year; (b) Is not a high school graduate; (c) Has
       not received a general educational development (GED) certificate; and (d) Has withdrawn from
       school.

      No applicant will be accepted into the program without this certification being completed and
       received by ONGYCP.

By my signature below I certify as the legal guardian, that my child has or will meet the dropout eligibility
requirements set by the Federal National Guard Bureau and Oregon’s state mandated rules and regulations on
page #3 of the application. I confirm that my child has or will withdraw from high school prior to the
ONGYCP class start date.

I further understand that if at any time, ONGYCP learns that the applicant is not a high school dropout or has
not formally withdrawn from high school prior to the first day of the ONGYCP program, they shall be
immediately removed from the application process or dismissed. ONGYCP reserves the right to pursue
legal proceedings “if” false information was or has been provided in this section or any section of the
application.

Legal Guardian Name - person authorized to sign the participant into ONGYCP (Print) ________________________

Legal Guardian (signature) __________________________________________________Date__________________

Applicant (Print) _________________________(Sign)______________________________Date__________________




           Class 40: Revised 2-26-10                                                         Page 8 of 42
      ONGYCP PHYSICAL (PAGE 1 of 2) WILL NOT BE ACCEPTED WITH MISSING SIGNATURES
  PHYSICIAN ONLY AUTHORIZED TO COMPLETE SECTION BELOW AT TIME OF PHYSICAL EXAM

    Patient Name ___________________________ DOB _____________ Age _____ Today’s date ____________
Drug Allergies?   No      Yes, What drug(s) and reaction ____________________________________________________________
Food Allergies?   No      Yes, What food(s) and reaction_____________________________________________________________
  YES NO Do you require a special diet ordered by a medical physician? (Yes block requires doctor’s written orders).
  YES NO Have you attended anger management?
  YES NO Have you been diagnosed with depression?
  YES NO Have you been in a residential treatment program?
  YES NO Have you had a history of anxiety or panic attacks?
  YES NO Do you have a history of bedwetting?
  YES NO Do you have a history of sleepwalking?
  YES NO Do you have a history of cutting? Explain__________________________________________________________
  YES NO Have you attempted suicide? Date _____________ How? _____________________________________
  YES NO If you have answered yes to the question above, have you been seen by a therapist, psychologist, or psychiatrist?
  YES NO Are you a smoker?
  YES NO Are you Attention Deficit Disorder? (ADD)
  YES NO Are you Attention Deficit Hyperactive Disorder? (ADHD)
  YES NO Do you have asthma?
  YES NO Have you ever had a seizure?
  YES NO Have you ever passed out with exercise?
  YES NO Do you have any current skin itching/rashes?
  YES NO Do you have seasonal allergies requiring treatment?
  YES NO Have you ever had numbness/tingling in arms, hands, and legs?
  YES NO Have you ever had a head injury/concussion that required hospital stay?
  YES NO Do you cough, wheeze and have trouble with breathing after exercise?
  YES NO Have you ever been knocked out, become unconscious, or lost your memory?
  YES NO Have you had a severe viral infection like Myocarditis or mononucleosis in the last month?
  YES NO Have you had a medical illness or injury since your last check up or sports physical?
  YES NO Has any family member/relative died of heart problem/sudden death before age 50?
  YES NO Has a physician ever denied/restricted your participation in sports?
  YES NO Do you use special protective/corrective equipment/devices not usually used for your sport/position?
(Examples: knee brace, retainer, hearing aide, etc.)_________________________________________________________
  YES NO Are you sexually active?
  YES NO Have you had vision/eye problems?
  YES NO Do you wear glasses, contacts, eyewear?___________________________________________________
  YES NO Have you had a sprain, strain, swelling in muscles, tendons, bones, joints, or any other problems? If
YES check the correct box: Head elbow hip neck finger forearm                  thigh   back    wrist   shoulder          knee
  chest hand shin/calf upper arm Ankle foot
Other________________________________________________________

Females only: Last menstrual period?_______________ Days in cycle between periods?____# of periods in last year?____
  YES NO Do you have problems with vaginal infections?
  YES NO Have you been treated for urinary tract infections?

Lab tests for sexually active participants:
Females:      Pap Smear___________ Gonorrhea__________               Chlamydia____________ Pregnancy Test_______
Males:     Gonorrhea__________ Chlamydia____________
What medication(s) does the applicant receive? List them below in the space provided.
            Medication                              Dose/Frequency                    Reason
_______________________________ _______________________________ _______________________________
_______________________________ _______________________________ _______________________________
List medications the applicant has received in the last 12 months______________________________________________
Applicant name (print)_______________________________signature____________________________ Date________
Parent/Guardian name (print)________________________________signature________________________ Date_____
Licensed Medical Provider (name) _______________________________________________________________
Licensed Medical Provider (signature)________________________________ MD DO NP PA Date_______
            Class 40: Revised 2-26-10                                                                     Page 9 of 42
         ONGYCP PHYSICAL (PAGE 2 of 2) WILL NOT BE ACCEPTED WITH MISSING SIGNATURES
  PHYSICIAN ONLY AUTHORIZED TO COMPLETE SECTION BELOW AT TIME OF PHYSICAL EXAM
Patient Name __________________________DOB _____________Age _____Today’s date____________
List past injury/s over the last three years that required/requires medical attention:
Injury______________________________ Date___________ Injury_____________________________ Date________
Injury______________________________ Date___________ Injury_____________________________ Date________
List current injuries that are requiring medical attention:
Injury______________________________ Date___________ Injury_____________________________ Date________
Are there any frequent physical symptoms that ONGYCP staff should be made aware of (vomiting, stomach issues,
headaches, chronic pain, etc)?_________________________________________________________________________
How does the applicant treat the symptoms?______________________________________________________________
Does the applicant have any orthopedic concerns?_________________________________________________________
What illegal drugs has the applicant used and how long ago?
a) drug________________ date______ b) drug________________ date_______ c) drug________________ date______
d) drug________________ date______ e) drug________________ date_______ f) drug________________ date______
Indicate last date of the following: Medical check:___________
Height________Weight______Pulse_________BP______/_______
Check (physician)                               List any abnormalities
  Appearance________________________________________________________________________________
  Eyes/Ears/Nose/Throat_______________________________________________________________________
                                                                              ATTENTION!
                                                                 Participants will be sub
  Lymph Nodes______________________________________________________________________________ j e c t
                                                                   to: High altitude (3000 +
  Heart/Lungs_______________________________________________________________________________
                                                                   feet) Adverse/Inclement
  Pulse_____________________________________________________________________________________ a l
                                                                   weather, Intense physic
  Abdomen_________________________________________________________________________________t o
                                                                   training, and exercise
                                                                   include running short/l
  Genitalia__________________________________________________________________________________o n g
                                                                   distances over various
  Skin______________________________________________________________________________________
                                                                   terrains. Participants
  Neck/Shoulder/Back_________________________________________________________________________
                                                                   receiving medications may
  Arm/Elbow/Forearm_________________________________________________________________________ T h e
                                                                   experience side effects.
                                                                   safety and security of t
  Wrist/Hand________________________________________________________________________________ h e
                                                                   participant is paramoun
  Hip/Thigh_________________________________________________________________________________ t
                                                                   o v e r a n y/ a l l s c e n a r i o s .
  Leg/Knee_________________________________________________________________________________
  Ankle/Foot________________________________________________________________________________
  Hernia____________________________________________________________________________________
List all Medical/Psych Diagnosis:      N/A________________________________________________________________
List previous surgeries and dates: N/A_________________________________________________________________
__________________________________________________________________________________________________
Discontinued medications within last 6 months: ___________________________________________________________
Comments:________________________________________________________________________________________
Licensed Medical Provider (name-print/type)_______________________________Phone(_____)___________________
Address___________________________ City____________ State____ Zip Code__________ Fax(_____)____________
Licensed Medical Provider:
At my level of professional experience/knowledge and based upon the final outcome/results of this evaluation
  I CLEAR/FIND          I DO NOT CLEAR/FIND this youth able to participate in any and all ONGYCP activities.
(Medical provider must check one of the above boxes.)
Licensed Medical Provider (signature)_____________________________ MD DO NP PA Date________

           Class 40: Revised 2-26-10                                                        Page 10 of 42
                                                  Oregon National Guard
                                                 Youth ChalleNGe Program
                                                    23861 Dodds Road
                                                     Bend, OR 97701
                                                    Phone (541) 317-9623
                                                     Fax (541) 388-9960
                                                       www.oycp.com




THIS EXAM MUST BE PERFORMED BY AN EYE DOCTOR
                                                                                            DATE__________________

To __________________, (Eye care facility)


Patients Name (Print) ____________________________

Your patient is an applicant for our program and requires a letter from an eye doctor specifying the information below. This
is a mandatory requirement for all applicants desiring acceptance into our school.

To make this a simpler process for your facility, please choose and mark the appropriate statements below followed by
your office stamp and signature. This will facilitate this requirement.

We will require having this form returned either by fax or mail in order for him/her to be considered for acceptance to our
program.

Your assistance in this matter is appreciated.


________          This individual HAS NORMAL eye health.


________          This individual HAS ABNORMAL eye health.




________          This individual REQUIRES corrective eyewear.


________          This individual DOES NOT REQUIRE corrective eyewear.




Please place your office stamp and signature here._________________________________




                                                   Frank A. Strupith
                                                   Admissions
                                                   Oregon National Guard Youth Challenge Program
                                                   (541)317-9623 ext 223



            Class 40: Revised 2-26-10                                                                    Page 11 of 42
                                                  Oregon National Guard
                                                 Youth ChalleNGe Program
                                                    23861 Dodds Road
                                                     Bend, OR 97701
                                                     Phone (541) 317-9623
                                                     Fax (541) 388-9960
                                                      www.oycp.com




                                                                                   DATE__________________
To __________________, (dental care facility)



Patients Name (Print full name) ________________________________


Your patient is an applicant for our program and requires a letter from his/her dentist stating that a dental examination has
taken place and that there is no pending or ongoing dental work anticipated through December of 2010. This is a mandatory
requirement for all applicants desiring acceptance into our school.

To make this a simpler process for your dental facility, please choose and mark the appropriate statement below followed by
a brief description of any anticipated dental work expected(IF APPLICABLE), your office stamp and signature. This will
facilitate this requirement.

We will require having this form returned either by fax or mail in order for him/her to be considered for acceptance to our
program.

Your assistance in this matter is appreciated.


________          This individual DOES NOT HAVE any anticipated/pending dental work identified

                  through December 2010.


________          This individual DOES HAVE anticipated/pending dental work needed through
                  December 2010.

    _________________________________________________________________________________________

_________________________________________________________________________________________

        (PLEASE GIVE A DESCRIPTION OF WORK NEEDED AND APPOINTMENT DATES)



Please place your office stamp and signature here._________________________________




                                                  Frank A. Strupith
                                                  Admissions
                                                  Oregon National Guard Youth Challenge Program
                                                  (541)317-9623 ext 223




             Class 40: Revised 2-26-10                                                                    Page 12 of 42
                                                    INSURANCE INFORMATION

      This is to be completed by the parent/guardian and must be legible or your application will not be accepted
                                            Attach front and back copy of Insurance Card

(Applicants) Last Name________________________________ First Name_______________________________ MI___

(Policy Holder) Last Name______________________________ First Name_______________________________MI___
Relation to applicant:        Grandparent    Legal Guardian   Other   Parent   Sibling   Spouse   Step-Parent      Self

Home Phone_________________ Work Phone__________________ Fax_______________ Cell __________________
Mailing Address__________________________________ City_____________________ State____ Zip code________
NOTE: I understand that my son/daughter will be cared for through my insurance if they become ill or injured.
(Proof of medical insurance is required) All medical costs are the parent/guardian responsibility.
Type of Insurance:            Medical     Prescription
Group#__________________________________Policy#_______________________________ Expiration Date_______
Physician (Name)_________________________________ Phone_________________ Ext_____ FAX_______________
co-pay information:__________________________________________________________________________________
Insurance Company (Name)________________________________Phone___________________ Fax________________
Insurance Company Address________________________________ City_______________ State___ Zip Code________
#2 Address_________________________________ City___________________ State ________Zip Code____________
I understand that I must provide my daughter/son with sufficient prescription medication during the program.
Prescription medications may be supplied by parent/guardian; refills may be called into the Bend, Oregon
SAFEWAY Pharmacy Department. To set up the account see Safeway registration form on page 24.




              Class 40: Revised 2-26-10                                                                         Page 13 of 42
 The following information is required to ensure we have the most up to date, accurate contact information for your
 ONGYCP Applicant and is a condition of the acceptance of your application. Incomplete addresses, phone numbers, etc.
 will not be accepted.
 APPLICANT CONTACT INFORMATION (Legal Name Only as listed on Birth Certificate or Court Document)
Name: Last____________________________ First _________________________MI____ Suffix:               Jr.   Sr.     I      II     III    IV
Home Phone_____________________ Work Phone_______________________ Ext______ Email____________________________
Fax__________________ Cell Phone__________________ Other _______________
County____________ Address #1________________________________City___________________State______ Zip Code________
Is address #1 your mailing address? Yes No
Address #2_____________________________City_______________State___Zip Code________
                            #1 PARENT/ LEGAL GUARDIAN CONTACT INFORMATION (MANDATORY)
Relation to applicant:        Grandparent   Legal Guardian   Other   Parent   Sibling   Spouse   Step-Parent
Name: Last____________________________ First __________________________MI____ Suffix: Jr. Sr. I II                             III    IV
Home Phone__________________ Work Phone__________________ Ext_______ Email_________________________
Cell Phone__________________ Authorized for applicant pickup: Yes No Legal Guardian: Yes No
Emergency Contact for the applicant? Primary Secondary No
County____________ Address #1_____________________________City_______________State___Zip Code________
Is address #1 your mailing address? Yes     No
Address #2_____________________________City_______________State___Zip Code________
                      #2 PARENT/LEGAL GUARDIAN CONTACT INFORMATION (if different from above)
Relation to applicant:        Grandparent   Legal Guardian   Other   Parent   Sibling   Spouse   Step-Parent
Name: Last____________________________ First __________________________MI____ Suffix: Jr. Sr. I II                             III    IV
Home Phone__________________ Work Phone__________________ Ext_______ Email_________________________
Cell Phone__________________ Authorized for applicant pickup: Yes No Legal Guardian: Yes No
Emergency Contact for the applicant? Primary Secondary No
County____________ Address #1_____________________________City_______________State___Zip Code________
Is address #1 your mailing address? Yes     No
Address #2_____________________________City_______________State___Zip Code________
                    #3 ALTERNATE CONTACT PERSON IN CASE OF AN EMERGENCY (MANDATORY)
Relation to applicant:  Grandparent Legal Guardian Other Parent Sibling Spouse Step-Parent
Name: Last____________________________ First __________________________MI____ Suffix: Jr. Sr. I II                             III    IV
Home Phone__________________ Work Phone__________________ Ext_______ Email_________________________
Cell Phone__________________ Authorized for applicant pickup: Yes No Legal Guardian: Yes No
Emergency Contact for the applicant? Primary Secondary No
County____________ Address #1_____________________________City_______________State___Zip Code________
Is address #1 your mailing address?  Yes    No
Address #2_____________________________City_______________State___Zip Code________
      FAMILY TRANSLATOR (MANDATORY FOR NON-ENGLISH SPEAKING PARENT/GUARDIANS)
Relation to applicant:        Grandparent   Legal Guardian   Other   Parent   Sibling   Spouse   Step-Parent
Name: Last____________________________ First __________________________MI____ Suffix: Jr. Sr. I II                             III    IV
Home Phone__________________ Work Phone__________________ Ext_______ Email_________________________
Cell Phone__________________ Authorized for applicant pickup: Yes No Legal Guardian: Yes No
Emergency Contact for the applicant? Primary Secondary No
County____________ Address #1_____________________________City_______________State___Zip Code________
Is address #1 your mailing address? Yes     No
Address #2_____________________________City_______________State___Zip Code________
                                                  ADDITIONAL INFORMATION
Do you know anyone else that is applying for this same class that you are? Yes No Are they related to you?             Yes       No
Name of person known_________________________Relationship to you? ____________________________

Name of Person who referred you to ONGYCP: Last____________________First_________________MI________
              Class 40: Revised 2-26-10                                                                        Page 14 of 42
                                APPLICANT STATISTICAL INFORMATION
Applicants Name: Last_______________________First____________________MI_________________________
1.        Date of Birth: (mm/dd/yyyy)_____________AGE___________
2.        Gender    Male         Female
3.        Ethnicity: Hispanic/Latino YES NO          Race:    American Indian/Alaskan Native Asian Black/African American
          For Race please select one or more.                Native Hawaiian/Other Pacific Islander White
4.        Primary Language you speak:____________________ Language spoken at home:____________________
5.        Does parent/guardian speak English? Fluent Little Not at all
6.        Are you married?: Yes No Number of children of your own________ Number of family members in your household?______
7.        What is the income level of your family$:                0-15,000      15-25,000           25-35,000         35-45,000      Over 45,000
8.        Hair Color:        Auburn             Black    Blonde      Brown       Red
9.        Natural Eye Color:            Blue       Brown     Green       Hazel Contact Eye Color:               Blue     Brown      Green       Hazel
10. Height (inches)__________ Weight (pounds/lbs)___________
11. Physical Markings (Tattoos, scars, birthmarks, etc.):___________________________________________________
12. Are you a high school drop out? Yes No Name of last School Attended:________________________________
    How long have you been a drop out? Less than 1 year 1 year or greater
13. Do you have a              GED             High School Diploma       Other Certificate
14. Do you have any known learning disabilities? __________________________________________
15. How many times have you been suspended from high school?                             1      2    3    4      5     Greater than five: How many?________
16. Are you home schooled?                      Yes     No If yes, by whom? _______________________________________________
17. Are you affiliated with or have a history of gang relations?                       Yes     No
18. Do you or a member of your household receive Public Assistance?                             No       Food Stamps       Cash Aid       Medical
            Free/Reduced school lunch                 Other________________________
19. Are you in the care, custody and supervision of the state of Oregon or court of Oregon?
            Ward of the State             Ward of the Court         Neither
20. How long have you lived in Oregon? Years____ Months___
     a)     In what state were you born?______________________________________________
     b) Do you intend to stay in Oregon?                   Yes      No
21. How many times have you been arrested?____ a) date____/____/____ crime ________________________________
          b) date____/____/____ crime ________________________ c) date____/____/____ crime______________________
22. Are your parents              Legally Separated          Divorced         Married        Other_____________________________
23. Who do you live with?
          Grand-Parent(s)                      Legal Guardian(s)      Other     Parent(s)       Sibling       Spouse     Step-Parent(s)
24. Are you a           Foster Child             Adopted    Homeless          None of These
25. How did you find out about ONGYCP?
Newspaper (list publication)_______________________ Friend Website HS Counselor Media YMCA
   Law Enforcement Agency Juvenile Department Employment Department Services to Children and Families
   Department of Human Resources/Self Sufficiency Center Armed Forces Recruiter Former ONGYCP Participant
   Boys and Girls Clubs of America Transient Shelter Other (describe) ___________________________________

26. Have you ever been a prior Candidate/Cadet at any National Guard Youth Challenge Program? Yes No
    Why did you leave? Own request Parent/Guardian request Disciplinary reasons Drug test Medical reason

28. Have you ever been a prior Applicant to ONGYCP? Yes No When/Which class?_______________________
    Why were you not accepted?      Lack of space Not eligible Did not finish application Medical reason Unknown

29. Do you have any dietary restrictions or considerations?                      No      Yes_________________________________________




                   Class 40: Revised 2-26-10                                                                                                Page 15 of 42
                    WHAT WILL IT BE LIKE AT ONGYCP? (All parties Read, Sign, and Submit)

MODEL:
Entire program model is based upon Oregon National Guard military standards, values, and guiding principals.
Red stage (WEEKS 1 & 2 of residential):
• Very physical, highly structured, extreme discipline and very intense.
• Drill Instructor Model: The platoon will be managed through high volume drill instruction; Drill Instructors will yell; it
   will be different than public school and similar to a Military Basic Training model.
• Everything you do will be by the numbers: We will teach you how we want you to dress, shower, brush your teeth, how
   to make your bed, etc.
• Everything will be based upon TEAM/PLATOON performance. When mistakes or errors occur, often the result will be
   platoon group intervention. I.e. PUSH UPS
• You will learn the military model, military courtesy, cadet handbook, how to march, rules, policies, how to interact
   within the platoon and throughout the program.
White and Blue stage (WEEKS 3-22 of residential):
• There will be a significant shift to an academic focus.
• There will be teachers who care and want you to succeed.
• There will be extra help and tutoring available.
• There will be homework at least 4 days per week and extra help provided.
• Time will be spent outside in the community through service learning activities, field trips and off-site activities.
• Physical fitness training will occur daily.
• Participants will maintain facility cleanliness standards.
THINGS TO CONSIDER
• You will live as a team/group. Likewise, you will be held accountable as a team/group. This includes physical training,
  team development, and being held accountable when others on your team/platoon are not catching on as fast or always
  doing things right.
• You eat 3 balanced meals and an evening snack, provided daily.
• Health, hygiene and showers are done daily.
• You will be living and sleeping in an open bay/barracks. Lights on at 6am, light out at 9:30pm.
• There will be differences and disagreements. You will be expected to responsibly problem solve.
• There is zero -0- tolerance for disrespect, anger, acting out against others, bullying, fighting, or lying.
• You do it our way and on our terms.
THINGS TO REMEMBER
• The people here CARE about you personally, your success, your personal growth and reaching your full potential. This
  is the reason we are here!
• Get ready and prepare early. (Mentally and Physically)
• You can do the program; 70,000 other kids just like you, with similar situations, learning disabilities, families, etc. have
  done it and are doing well.
• DO NOT take the model, activities, intensity or team/platoon discipline personally; it’s a model…a process…the
  military way.
• You will increase your reading, math and language abilities tremendously. You have an opportunity to earn a High
  School diploma (with enough credits), GED if eligible, and credit recovery up to 8 school credits.
• You will be a better person, have self-confidence and improved self-esteem when you graduate.
• You will have a successful placement plan to act on after you graduate.
• You will have a lot of people who care and are pulling for you.

Parent/Custodial (Legal Guardian)-Print_________________________Sign__________________________________

By my signature, I have read and understand the above information Date____/____/______

Applicant-Print____________________________Sign______________________________________________

By my signature, I have read and understand the above information. Date____/____/______



             Class 40: Revised 2-26-10                                                                   Page 16 of 42
          PARENT/GUARDIAN UNDERSTANDING/AGREEMENT TO PARTICIPATE IN ONGYCP

I am the parent/legal guardian of _______________________________________________________________________
                                                     (Print name of applicant)

I have attended a mandatory ONGYCP orientation and understand the expectations, conditions, and responsibilities
associated with my daughter’s/son’s participation in the program. I understand and agree to the following:

1. I’m the parent/legal guardian of the participant named above and have the legal authority to enroll the applicant into
   ONGYCP.

2. I understand and agree to personally pick my child up and return them at the designated time during program breaks. I
   understand the program will not arrange or facilitate any travel alternatives (bus, plane, taxi etc.) regardless of weather,
   travel/automobile limitations, work, or personal obligations. I understand that if I fail to meet this obligation that my
   child will be terminated from the program and allowed to re-apply, if eligible, for a later class.

3. I understand that I’m responsible for all prescription medications. The program medical staff will attempt to contact me
   not more than two times to seek prescription medication assistance. After the second attempt, if the parent fails to
   respond to assist, the participant will be sent home and allowed to re-apply, if eligible, for a later class.

4. I understand/agree that because of medical emergency, legal issues and coordination issues that I must provide an
   updated address, phone, and emergency contact that is current at all times. I understand and agree to notify the program
   immediately of any address, phone number, or emergency contact change that will prevent program staff from reaching
   me immediately in the event of emergency. In the event I will be out of town, I agree to notify the program staff in
   advance and make arrangements for contact and emergency care of my child.

5. I understand that a condition of entrance, acceptance, and retention in the program is to have a qualified committed and
   willing mentor for my child in order to remain in the program. If it is learned that the mentor is not committed, not
   willing to attend training or meet required National Guard Bureau standards, my son/daughter may not
   continue/graduate from the program. This is a National Guard Bureau mandate in order to be accepted and continue
   participation. Mentors will be contacted within the first month to verify full commitment, training date and willing
   participation. Failure/rejection to be a mentor will result in participant termination. They may re-apply for a future
   class if eligible.

6. Participants will be issued clothing and equipment. The participant is responsible for this issue while attending the
   program. If they lose or fail to turn in issued equipment, they must pay for replacement before they can receive school
   credits, GED, diploma, or graduate. Payment to the program must occur prior to graduation.

7. This is a 100% “ALL OR NOTHING” program! No credits, transcripts, test scores, GED grades will be provided or
   awarded unless the enrollee completes the entire program and graduates. If they quit, leave early or are terminated, they
   shall receive nothing as if they had never attended.

8. I understand that ONGYCP employs a “Hands Off” Leadership concept. “Hands Off” means that no staff member may
   touch a cadet or use abusive language as a means of coercion. Challenge staff is expected to lead through positive
   methods that do not include the use of physical force or verbal abuse.

9. I give full permission to ONGYCP for my son/daughter to have his/her photo taken, have video with sound taken,
   and/or to be interviewed for purposes of brochures, newsletters, media, slide presentations, and other publications.

Parent/Custodial (Legal Guardian) Print_______________________________Sign_______________________________

By my signature, I have read and understand the information described above. Date_______________________________

Applicant (Print)___________________________________________Sign_______________________________

By my signature, I have read and understand the information described above. Date_______________________________

             Class 40: Revised 2-26-10                                                                   Page 17 of 42
                                         ONGYCP PARTICIPATION AGREEMENT

I understand the questions on this application form and state that my answers are true to the best of my knowledge.
ONGYCP reserves the right to dismiss participant from the program and/or pursue formal legal proceedings “if” false
information was or has been provided in the application

During the 22 week residential phase, there is one family visitation at the program facility that is scheduled in advance by
ONGYCP. For purposes of security, safety, and control the following requirements are policy: Visitors are limited to
parents, legal guardians, siblings, and/or grandparents. Girlfriends/boyfriends shall NOT attend visitation. Visitors are
required to remain inside the building for the duration of their onsite visit. Visitors must leave unnecessary items in their
vehicles (i.e., purses, cell phones, backpacks, fanny packs, tobacco etc.). Items brought into this Federal facility are subject
to search by staff. Visitors will remain in the designated visitation area. Staff members will be present and available for
questions and answers.

Prior to and upon arrival participants agree to the following:
• Commit to memory your social security number (SSN) (this is so you may participate in certain educational
    activities).
• Rules in the “Cadet Handbook” are mandatory and will be followed.
• Listen, obey, and follow through with all orders and commands that are given by the staff, instructors and/or
    administrative personnel both oral and written. ONGYCP will not give any order or directive compromising the safety,
    well-being, and integrity of all concerned.
• No hairpins or barrettes.
• No phone or email privileges.
• No Smoking. Tobacco Free Campus (Oregon State Law)
• Jewelry of any kind is not allowed.
• Money will NOT be sent or given.
• Boyfriend/girlfriend relationships within the program residential phase will not be permitted or tolerated.
• Attend all classes.
• March in formation.
• Be silent (unless ordered otherwise).
• Participate in all class studies.
• Participate in service learning which involves physical exertion and travel throughout the community.
• Participate in Physical Training. (PT)
• Maintain daily personal hygiene.
• Safety and well-being of others and yourself is a priority at all times.
• This is a “Drug Free Program”. Any use of or attempt to use, will not be tolerated and will result in immediate
    dismissal from this program. Any misuse of prescription medication will not be tolerated.
• Staff or facility personnel will confiscate contraband. (Such items include, but are not limited to: make-up, weapons,
    gum, jewelry, electronic devices, lighters/matches, etc.). Personal belongings, including mail, will be searched for
    contraband.
• Any assault or contact (physically, verbally or sexual) including provoking, bothering, irritating or teasing people or
    encouraging others to do the same will not be tolerated.
• Be on time to all sessions, formations, classes and meetings in the proper uniform and with the proper equipment.

                            ONGYCP PARTICIPATION AGREEMENT CONTINUED ON PAGE 19




             Class 40: Revised 2-26-10                                                                    Page 18 of 42
                         CONTINUED ONGYCP PARTICIPATION AGREEMENT FROM PAGE 18

•   Clean and maintain all areas, respecting the property area of others. Do not deface, destroy, write, mark or graffiti on
    oneself, clothing, equipment or property.
•   Clean the living quarters, bathroom and kitchen (daily).
•   Address peers and staff by last name.
•   Use the chain of command to resolve complaints or issues.
•   Wear the ONGYCP uniform with pride. (i.e., no sagging pants, shirt will be tucked in, etc.) Representing a gang with
    graffiti, hand signs, body stance, sneaker shoestrings, or other ways of wearing clothing that may appear gang related is
    not tolerated.
•   Inform staff of medications prescribed by a licensed medical provider. Report all injuries/illnesses to ONGYCP staff in
    order to receive timely and appropriate treatment. The ONGYCP Certified Nurse Practitioner will evaluate health and
    welfare of each participant.
•   Abide by ONGYCP safety instructions, standards and rules.
•   I understand that ONGYCP is competitive and can accommodate up to 156 participants each class. Submitting a
    complete application does not guarantee acceptance into the program. I understand ONGYCP will review/screen my
    application to determine potential eligibility.
•   I will honor my commitment to complete the program. I will not leave the program site, run away or hide. I will not
    lie, cheat, or steal or tolerate others who do.
•   I understand that ONGYCP employs a “Hands Off” Leadership concept. “Hands Off” means that no staff member may
    touch a cadet or use abusive language as a means of coercion. Challenge staff is expected to lead through positive
    methods that do not include the use of physical force or verbal abuse.
•   I understand that I will have my photo taken, have video with sound taken, and/or to be interviewed for purposes of
    brochures, newsletters, media, slide presentations, and other publications.
•   I understand, priority shall be extended to all 18 year olds, followed by 17 and then 16 year olds. In addition, the
    Admissions Unit shall consider applicants by geographic region that reflect the Oregon High School drop out
    demographics of the state

Parent/Legal Guardian-print_______________________Sign________________________Date____/____/____

Applicant-print____________________________ Sign_________________________ Date____/____/_____




             Class 40: Revised 2-26-10                                                                  Page 19 of 42
                                    FAMILY EDUATION RIGHTS AND PRIVACY ACT (FERPA)

The Family Educational Rights and Privacy Act (FERPA) afford parents and students over 18 years of age ("eligible
students") certain rights with respect to the student's education records. These rights are:
(1) The right to inspect and review the student's education records within 45 days of the day the School receives a request
    for access. Parents or eligible students should submit to the Lead Teacher a written request that identifies the record(s)
    they wish to inspect. The School official will make arrangements for access and notify the parent or eligible student of
    the time and place where the records may be inspected.
(2) The right to request the amendment of the student’s education records that the parent or eligible student believes are
    inaccurate. Parents or eligible students may ask the School to amend a record that they believe is inaccurate. They
    should write the School principal, clearly identify the part of the record they want changed, and specify why it is
    inaccurate. If the School decides not to amend the record as requested by the parent or eligible student, the School will
    notify the parent or eligible student of the decision and advise them of their right to a hearing regarding the request for
    amendment. Additional information regarding the hearing procedures will be provided to the parent or eligible student
    when notified of the right to a hearing.
(3) The right to consent to disclosures of personally identifiable information contained in the student's education records,
    except to the extent that FERPA authorizes disclosure without consent. One exception, which permits disclosure
    without consent, is disclosure to school officials with legitimate educational interests. A school official is a person
    employed by the School as an administrator, supervisor, instructor, or support staff member (including health or medical
    staff and law enforcement unit personnel); a person serving on the School Board; a person or company with whom the
    School has contracted to perform a special task (such as an attorney, auditor, medical consultant, or therapist); or a
    parent or student serving on an official committee, such as a disciplinary or grievance committee, or assisting another
    school official in performing his or her tasks. A school official has a legitimate educational interest if the official needs
    to review an education record in order to fulfill his or her professional responsibility.
(4) The right to file a complaint with the U.S. Department of Education concerning alleged failures by the School District to
    comply with the requirements of FERPA. The name and address of the Office that administers FERPA are:
    Family Policy Compliance Office
    U.S. Department of Education
    400 Maryland Avenue, SW
    Washington, DC 20202-5901

It is the policy of the ONGYCP to release applicant/participant information, records and files in accordance with the Family
Education Rights and Privacy Act of 1974 (FERPA). The FERPA requires ONGYCP to provide “advance” information to
parents, guardians and participants 18 years of age or older regarding information the program will release about
participants and to whom.

                 Information/records will be released under FERPA under the following circumstances:

1. To other school officials, including teachers who have legitimate educational interests in the information.
2. Officials of other schools that the participant seeks to enroll in as long as the participant is notified of the transfer of
   documents and has the opportunity to challenge the content. (Oregon law ORS 326.575 requires within 10 days of initial
   enrollment in a public or private school, the school must notify the former school and the former school must transfer all
   educational records related to the participant to the new school.)
3. State educational authorities, Department of Education or the Attorney General.
4. State or local officials if the disclosure concerns the juvenile justice system and its ability to serve the participant, prior
   to adjudication, as long as officials certify in writing that the officials will not release the information to others.
5. Accrediting/auditing organizations.
6. Parents of a dependent participant.
7. Appropriate persons in health and safety emergencies.
8. A person designated in a lawfully issued subpoena as long as the educational agency makes a reasonable attempt to
   contact the parents before complying with the subpoena.
9. ONGYCP must disclose to the extent possible, participant information to: a) Law Enforcement, child protective
   services and health care professionals in connection with a health and safety emergency if the information is necessary
   to protect the participant; b) Courts and state/local juvenile agencies if related to the courts/agency ability to serve the
   needs of the participant prior to adjudication. Persons receiving information must certify in writing that the information
   will not be disclosed. Continued on next page.

             Class 40: Revised 2-26-10                                                                      Page 20 of 42
                  FAMILY EDUATION RIGHTS AND PRIVACY ACT (FERPA) Continued
Continued from previous page.
10. Mentors designated by the ONGYCP and the cadet will receive a copy of the Cadet Action Plan which contains various
    scores and results from the cadets achievements at ONGYCP, along with the names and addresses of the cadet and
    cadet’s Parents/Guardians. All mentors receive training and sign an agreement to comply with FERPA confidentiality.

By your signature below, you are acknowledging and authorizing the release of information and that you have been
provided advance notice under FERPA. Due to the nature and the structure of the ONGYCP you are giving your consent
that we display and give verbal announcements of scores, grades, and results of assignments, packets, projects and tests
within the constraint of the classroom, living and work areas (You are encouraged to review the FERPA law if you have
question or want additional information regarding your rights.)

Parent/Legal Guardian (Print)_________________________________Sign_____________________________

By my signature, I authorize ONGYCP to release information under FERPA as described above.
Date___________________

Applicant (Print)_____________________________________________Sign_____________________________

By my signature, I authorize ONGYCP to release information under FERPA as described above.
Date__________________

                                         ONGYCP NOTICE FOR DIRECTORY INFORMATION

The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that ONGYCP with certain exceptions,
obtain your written consent prior to the disclosure of personally identifiable information from your child's education
records. However, ONGYCP may disclose appropriately designated "directory information" without written consent, unless
you have advised ONGYCP to the contrary in accordance with ONGYCP procedures. The primary purpose of directory
information is to allow the ONGYCP to include this type of information from your child's education records in certain
school and outside agency publications. Examples include: The class yearbook, honor roll or other recognition lists,
graduation programs, public announcements of events.

Directory information, which is information that is generally not considered harmful or an invasion of privacy if released,
can also be disclosed to outside organizations without a parent's prior written consent. Outside organizations include, but are
not limited to, companies that manufacture class rings or publish yearbooks. In addition, two federal laws require local
educational agencies (LEAs) receiving assistance under the Elementary and Secondary Education Act of 1965 (ESEA) to
provide military recruiters, upon request, with three directory information categories - names, addresses and telephone
listings – unless parents have advised the LEA that they do not want their student's information disclosed without their prior
written consent.

If you do not want ONGYCP to disclose directory information from your child's education records without your prior
written consent, you must notify the ONGYCP in writing 7 days before the in-processing date. ONGYCP has designated the
following information as directory information:
     Student's name, address, telephone listing, email address, age
     Parent/Guardian name, address, telephone listing, email address
     Participation in officially recognized activities and service to community events
     Photograph/Video with sound
     Degrees, honors, and awards received
     Grade level, dates of attendance, Current / prior educational status
     The most recent educational agency or institution attended

Footnotes:
1.These laws are: Section 9528 of the ESEA (20 U.S.C. 7908), as amended by the No Child Left Behind Act of 2001 (P.L.
107-110), the education bill, and 10 U.S.C. 503, as amended by section 544, the National Defense Authorization Act for
Fiscal Year 2002 (P.L. 107-107), the legislation that provides funding for the Nation's armed forces.


             Class 40: Revised 2-26-10                                                                   Page 21 of 42
                               ONGYCP CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

Applicant’s date of birth (mm/dd/yyyy) ____________________ Current County where you live____________________
Previous counties lived in________________________ , _______________________ , ___________________________
I, ___________________________________                    _________________________________                     __________________
          (Applicant Last Name)                                    (First Name)                                        (MI)
authorize the State of Oregon, any other state, its counties, its cities and its agencies to submit and or exchange all pertinent information
with the Oregon National Guard Youth Challenge Program regarding but not limited to the following: substance abuse history, referral
history, court status, social, family, medical and any information as specifically requested by the Oregon National Guard Youth
Challenge Program regarding the welfare and quality of life of the applicant mentioned above for the purpose of coordinating services.
   I understand that my records are protected under the Federal or State Confidentiality Regulations and cannot be disclosed without my
written consent unless otherwise provided for in the regulations. ONGYCP is in compliance with the most prominent of the federal
protections for participant privacy; Family Educational Rights and Privacy Act (FERPA), also known as the "Buckley Amendment".
FERPA protects the confidentiality of participant records to some extent, while also giving participants the right to review their own
records.
   I also understand that I may revoke this consent at any time except to the extent that action has been taken and that in any event this
consent expires automatically thirty-six months (36) to the date applicant’s official status is verified as “registered” by way of Oregon
National Guard Youth Challenge Policy.
Parent(s)/legal guardian(s) name (print & sign) _______________________________________________________
Parent(s)/legal guardian(s) mailing address: _____________________________________________________________
Parent(s)/legal guardian(s) physical address: _____________________________________________________________
Executed this (Day) ____ of (Month)______________, (Year)200_____ Applicant (signature)___________________________

               --------------------APPLICANT: STOP HERE, DO NOT CONTINUE ON THIS PAGE--------------------
From: Admissions Recruiter, Oregon National Guard Youth Challenge Program
To: Agency/agency representative (as specified/indicated below)
Subject: Respectfully request release of confidential information of said individual
The purpose of this request is to acquire information about said participant indicated above. Information you provide will better assist in
considering and/or determining this participant’s potential eligibility for the ONGYCP. Refer questions to Admissions Recruiter 541-
317-9623 Ext. 223. Space is provided toward the bottom of the page for your comments and/or narrative.

                         JUVENILE DEPARTMENT (our request)              OR         CIRCUIT COURT (our request)
  Public info. document       Background check/face-sheet W/disposition(s)       Police report     Psychological Evaluation
                               Clearly check the box(s) that apply to the youth identified in the above:
    currently on parole    currently on formal probation     current pending charges      currently under indictment
    currently charged     awaiting sentencing    free of felon/adjudication/conviction     free of capital offense(s) free of any and
all assault(s) (sexual/domestic/person-to-person/other)      known gang related ties/activities

                   DEPARTMENT OF HUMAN SERVICES SELF SUFFICIENCY PROGRAM (our request)
  Verification of services rendered to applicant/family Food Stamps Cash Aid Medical All Services

                                           EMPLOYMENT DEPARTMENT (our request)
  Verification of services rendered to applicant/family Unemployment benefits Other__________________________________

                                             EDUCATIONAL INSTITUTION (our request)
  Transcript (current or past copy)        Behavioral

                                                       MEDICAL
The following is requested:____________________________________________________________________________

                                                         OTHER
The following is requested:____________________________________________________________________________

Responding agency comments/narrative: __________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
               Class 40: Revised 2-26-10                                                                             Page 22 of 42
                                  ONGYCP UNDERSTANDING OF LIMITED MEDICAL SERVICES

ONGYCP has very limited medical services available to the participant. Services are limited to emergency care or transport and a
weekly sick call service intended to care for minor illnesses that a participant might experience in the traditional school district system.
We are unable to provide any “on going” treatment or care. We are unable to accept applications from individuals who will require on-
going medical or dental care that originated prior to arrival at the program or develops while in the program and prevents full
participation on a daily basis. Parents/Guardians are to take care of all medical/dental/vision matters that will prevent participation or be
a distraction during the program. Staff resources are not available to transport participants to ongoing medical, dental/vision
appointments. Medical/dental/vision care is to occur during the breaks when the participants are home.


              THE FOLLOWING CONDITIONS MAY PREVENT ENTRANCE INTO THE PROGRAM
   Extensive use of multiple medications necessary to treat multiple conditions on a daily basis.
   Current/previous injuries/surgeries that prevent everyday participation in all physical and mental ONGYCP activities.
   Dental services: braces adjustments, broken teeth, cavities, abscess and mouth disorders that impact/prevent the ability of the
    applicant to participate without on site care or assistance. Dental Care/Service is not available.
   Conditions or medications that adversely react or have side effects impacted by the high intensity physical activity and seasonal
    weather conditions that compromise the safety, health and welfare of the participant(s). Medications/conditions that may react
    adversely to extreme summer heat, winter cold and higher altitude.
   Historic or current conditions requiring medical, psychological or psychotic intervention for suicide treatment, manic depression,
    anxiety, etc. Mental health services are not available from ONGYCP
   All conditions above must be disclosed at time of application. If it is learned after the applicant arrives at ONGYCP that these
    conditions exist, the participant will be dismissed from the program and sent home. ONGYCP cannot and will not assume financial
    or personal liability/risk/injury for participants that have previous medical, physical or mental histories that could/would be
    impacted by the rigorous activities of the program. Applicants must have a full service medical physical examination and work up
    completed no earlier than the first orientation date of the class for which applying for by a licensed medical provider. All injuries,
    dental/medical/vision conditions must be resolved and the applicant free from additional required care prior to entrance into the
    program.
   Participants with dental or medical needs that require immediate “emergency” care, offsite time away from the program or that
    prevent participation will be dismissed and sent home. They may re-apply for a future class.
   Extensive dietary restrictions medically required by a medical physician.
                (Re-applying for a future class does not constitute a guarantee that the applicant will be accepted.)


                                                MEDICATIONS/MEDICAL CARE
   All required prescription medications must be disclosed in advance during the application process.
   All potential side effects and limitations of required medications must be disclosed at time of application.
   A medical release, approval and signature must be provided by the doctor in advance (pages 9 & 10) stating: applicant can safely
    participate in extreme hot, cold and high altitude conditions while consuming required prescription/medication(s).
   Parents/guardians are entirely responsible for all prescription medications and re-fills during the program.
   Parents/legal guardians are responsible for all required medical/dental/psychological care before, during and after participation in
    the ONGYCP.
   Injuries/physical/medical changes or new medications required by the applicant after the initial physical examination must be
    disclosed in writing prior to entry into the program for purposes of review, safety, health and welfare.


           PARENT/GUARDIAN ACKNOWLEDGEMENT AND SIGNATURE OF MEDICAL RELEASE
I understand and agree that I’m responsible for all medical/dental/mental health care of my child during, before and after participation in
ONGYCP. By my signature below, I’m indicating that I have read the above medical information. I, the undersigned, do hereby
authorize in the event of a medical emergency or medical transport to a local clinic or hospital, any physician or trained medical staff to
provide medical care to my son/daughter. I furthermore voluntarily authorize the Oregon National Guard Youth Challenge Program
Director or designee to authorize employees/contract personnel to provide medical treatment for my son or daughter.


Legal Guardian: Relation to applicant: Grandparent Legal Guardian Other Parent Sibling Spouse Step-Parent
Legal Guardian Name (Print)________________________________________________________________
Legal Guardian (Signature) ____________________________________________Date________________
Applicant Name (Print)         ________________________________________________________________
Applicant (Signature)          ____________________________________________Date________________

               Class 40: Revised 2-26-10                                                                             Page 23 of 42
                                 ONGYCP Safeway Pharmacy (Bend) Registration Information
                            To be completed by parent/legal guardian of applicant and must be legible

                                        APPLICANT HOME OF RECORD INFORMATION

Applicant Name: (Last)____________________________________(First)____________________________(MI)_____
Street Address: _____________________________________________________________________________________
City: _______________________               State: _____________________ ZIP: ___________
Phone: _____________________                Work Phone: ________________          Cell____________
Date of Birth: (mm/dd/yyyy)___/___/___          Sex: Male/Female

                                                APPLICANT INFORMATION
Known drug allergies: _______________________________________________________________________________
Do you have Diabetes? YES / NO
Do you have Asthma? YES / NO
Do you have High Blood Pressure? YES / NO
Other Medical Conditions? ___________________________________________________________________________


List any medication you are currently taking, including non-prescription medications: _____________________________
___________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________



                                           MEDICAL INSURANCE INFORMATION
Name of insurance company __________________________________________________________________________

Rx Bin Number____________________________________________________________________________________
(usually found in small print on the back of the insurance card)

Policy Number _____________________________ Group Number___________________________________________

Do you want generic drugs when available?                  YES / NO



You must set up a method for co-payment with the Safeway Pharmacy. Located at: 642 NE 3rd (intersection of NE 3rd
& Franklin Street), Bend OR, 97701. (541) 312-6486 (option #4). The Safeway Pharmacy must receive the co-
pay/payment before your child can receive any prescription medication.

Please identify the order the child is born in the household. (Example: First born, second born) Born_________________

Applicants Name (print)____________________________ (sign)__________________________Date__________

Parent/Legal Guardian (print)________________________ (sign)__________________________Date__________




            Class 40: Revised 2-26-10                                                                   Page 24 of 42
           APPLICANT JOB HISTORY/DESIRED JOBS AND SKILLS ENJOYED (MANDATORY)

                                        LIST YOUR EMPLOYERS OVER THE LAST TWO YEARS
                                                   (Include all work paid or unpaid)

APPLICANT NAME (PRINT)__________________________

Employer Name:______________________________ Employer phone number:_____________________
Address (street number/P.O. Box):_______________________________ City:_______________ State:___ Zip________
Job title:_______________________________________
Job duties:_________________________________________________________________________________________
__________________________________________________________________________________________________
List the time frame(s) of your employment with this employer: From______/____/____   To:______/____/____
                                                                 Month Day Year       Month Day Year


                                              SECOND MOST RECENT EMPLOYMENT
Employer Name:______________________________ Employer phone number:_____________________
Address (street number/P.O. Box):_______________________________ City:_______________ State:___ Zip________
Job title:_______________________________________
Job duties:_________________________________________________________________________________________
__________________________________________________________________________________________________
List the time frame(s) of your employment with this employer: From______/____/____   To:______/____/____
                                                                 Month Day Year       Month Day Year


                                  THIRD MOST RECENT EMPLOYMENT/VOLUNTEER WORK
Employer/Volunteer Agency:______________________________ Employer phone number:_____________________
Address (street number/P.O. Box):________________________________City:_______________ State:___ Zip________
Job title:_______________________________________
Job duties: (list skills)________________________________________________________________________________
 __________________________________________________________________________________________________
List the time frame(s) of your employment with this employer: From______/____/____ To:______/____/____
                                                                 Month Day Year     Month Day Year

Volunteer experience:________________________________________________________________________________

__________________________________________________________________________________________________




            Class 40: Revised 2-26-10                                                       Page 25 of 42
                              APPLICANT GOALS (COMPLETION BY APPLICANT MANDATORY)
                         APPLICANT NAME (PRINT)__________________________________________
If given the choice which of the following placement opportunities would you choose?
     Opportunity to earn up to 8 Certified High School Credits and return to hometown high school
     Opportunity to enlist in the Military Service
     Opportunity to enroll in College
     Opportunity to enroll in Vocational Training
     Opportunity for Employment
The National Guard Challenge Program is committed to the education of young people. Success in this program requires
careful planning, personal commitment, hard work, and a clear focus. In order to maximize the benefits of this program,
you must be focused with clear goals. ONGYCP will not consider your application unless your goals are clearly listed.

A)        List your goals for the next year and a half. (Goal # 1= 6 month, Goal # 2= 12 month, Goal # 3= 18 month)
     Goal #1 (6 month): ______________________________________________________________________________
                                 ______________________________________________________________________________
     Goal #2 (12 month): ______________________________________________________________________________
                                  ______________________________________________________________________________
     Goal #3 (18 month): ______________________________________________________________________________
                                  ______________________________________________________________________________

B)        Write a statement of what your life will be like one year after graduating from ONGYCP.
__________________________________________________________________________________________________

__________________________________________________________________________________________________

C)     How can ONGYCP help you achieve these goals?
 _________________________________________________________________________________________________
 _________________________________________________________________________________________________
                                           Placement is Mandatory to Graduate
In order to graduate from ONGYCP, the participant must have a verifiable placement: high school, employment, military,
vocation, college, volunteer experience or other approved placement before graduation. You must develop a placement plan
and be pursuing that plan while at ONGYCP. If you do not have verifiable placement prior to graduation you will not
receive the ONGYCP certificate of graduation.
Applicant Name (print)_____________________________ Signature_____________________________ Date _______




               Class 40: Revised 2-26-10                                                               Page 26 of 42
                                    OREGON NATIONAL GUARD
                                   YOUTH CHALLENGE PROGRAM
                                                     23861 DODDS ROAD
                                                    BEND, OREGON 97701
                                                        (541) 317-9623
                                                      FAX (541) 388-9960




                           MENTOR PROGRAM
                         APPLICATION BOOKLET
Participant: Attached are two mentor application booklets. Give one to each of your potential mentors to fill out and
submit.
Mentor Applicant: Complete this application. Participant or Mentor Applicant can mail the application directly to:
                                         Oregon National Guard Youth Challenge Program
                                                     23861 DODDS ROAD
                                                       BEND, OR 97701
                                                         MENTORS
Young people want support. The majority of young people cite parents or other adults as the first source of advice regarding
personal problems. There was a time when our society was made up of extended families and close communities. Aunts,
uncles, cousins and family friends often served naturally as mentors. While families bear the primary obligation to care for
their children and to help them become healthy contributing citizens, other institutions can help families acclimate to a
rapidly changing world. A mentor can provide the nurturing, supportive adult relationship absent in the lives of many of our
young people. Adolescents today are an increasingly isolated population. Changes in the structure of the family,
community, neighborhood relationships and in workplace arrangements have deprived young people of the adult contacts
that historically have been primary sources of socialization and support for development. Many young people lack positive
nurturing and supportive primary adult relationships. A mentor can provide that role, and perhaps more importantly, teach
and guide the young person to find others to fill that role as well. Mentor attributes: maturity, integrity, leadership,
commitment, availability, compatibility and responsibility
                                          ONGYCP Mentor Eligibility Requirements
   An Oregon resident: Currently living in Oregon 12 consecutive months without any break in time.
   Mentor must at least 21 years of age at the date of Mentor Training.
   The mentor and applicant must be the same gender/sex.
   The mentor must be willing to make a 14 month commitment.
   The mentor cannot be an immediate family member or anyone living in the same household as the applicant.
   The mentor is to be within the same geographic proximity as the participant (a distance that is not a travel burden to
    both the mentor/mentee).
   Mentors that are selected are required to complete a set of on-line mentor training modules prior to attending a six hour
    Mentor Training workshop in Bend, Oregon at the program facility: (23861 Dodds RD, Bend OR 97701)
    This training takes place after the youth has begun the program. Please note that all mentor training materials are
    available only in English.
   After completing ONGYCP Residential Phase, the participant and mentor are to have four hours of contacts per month,
    face to face between the mentor and mentee being the preferred method of contact. These contacts take place in the
    respective community of the mentor and participant.




             Class 40: Revised 2-26-10                                                                  Page 27 of 42
                                                  ONGYCP Mentor Disqualifiers
    A history of arrest and conviction for a sex offense
    A felony conviction within last five years
    Any alcohol, drug, substance abuse within last five years
    A history of domestic violence (reports, charges, conviction)
                                                     WHAT IS MENTORING?
Mentoring is a one-to-one relationship over a prolonged period of time between a youth and an adult who provides
consistent support, guidance and concrete help as the younger person may go through a difficult, challenging situation or
period in life. The goal of mentoring is to help youths gain the skills and confidence to be responsible for their own futures.
This includes an increasing emphasis on academic and occupational skills.
                                                Life issues in which mentoring helps

                            Teen pregnancy                           Work or school adjustment
                            Dropout prevention                       Job retention
                            Substance abuse                          Financial management/budgeting
                            Parenting skills                         Educational and career goals
                            Illiteracy                               Home ownership
                            Transition from welfare to work          College preparation
                            Employment preparedness
                                                        ONGYCP Mentoring
The Oregon National Guard Youth Challenge Program is a 17 month program that offers school dropouts an opportunity to
change their futures. The participants will live and work in a controlled, military environment that encourages teamwork
and personal growth. During this time they will work toward achieving their career or educational goals under the guidance
of a volunteer mentor from their home community.
The Oregon National Guard Youth Challenge Program consists of two phases. The first phase is residential, which includes
military structure, discipline, physical development, service to community and academic classroom instruction. The second
phase is the 12 month Post Residential Mentorship Phase.
The mentor relationship begins in the 11th week of the Residential Phase with a Mentor/Mentee Matching Ceremony in
Bend, Oregon. Each mentor is screened and trained prior to meeting with the cadet. From week 11 until the end of the 22
week Residential Phase, the mentor and the mentee correspond by way of letter writing. After the participant graduates you
will be required to contact the mentee at least four hours a month and report back to ONGYCP on a monthly basis.
                                                   ONGYCP MENTOR GOALS
 To seek and train responsible adults to mentor ONGYCP graduates
 Provide the mentors with training and support necessary for a successful mentoring relationship with the graduates
 Assist in creating and maintaining an open network of communication between all parties, to address issues and
  concerns that may arise during the 14 month mentorship
                                           SEQUENCE OF EVENTS FOR A MENTOR
1.   Cadet approaches mentors with applications.
2.   Mentors fill out and submit mentor applications to ONGYCP.
3.   Cadet selects primary and secondary mentors.
4.   Mentors are screened and interviewed by ONGYCP staff. (Mentor training instructions and dates will be scheduled
     during this interview.)
5.   Accepted mentors receive instructions to complete on-line mentor training modules prior to attending mentor training
     workshop and cadet match at ONGYCP facility.
6.   Non-selected mentors will receive a “thank-you for applying” letter.
7.   Mentors are required to correspond weekly with their cadet through letter writing/email during residential weeks 12
     through 22.
8.   Mentors are invited to attend graduation at week 22.
9.   Mentors begin contacts with mentee immediately after graduation for the next 12 months. (This is when the cadet needs
     you the most.) Mentors are required to have 4 hours of contact a month with their mentee, face-to-face being the
     preferred method, and report monthly to ONGYCP staff.
              Class 40: Revised 2-26-10                                                                  Page 28 of 42
                                             HOW CAN ONE APPLY?
A mentor application may be obtained by either visiting the website at www.OYCP.com or calling 541-317-9623 ext. 223.
A criminal background check will be conducted on all mentor candidates prior to being matched to a participant.

COLLECTION AND USE OF INFORMATION BY THE NATIONAL GUARD BUREAU
For purposes of applying as a mentor, you must disclose your personal information to the Oregon National Guard Youth
Challenge Program. The information you submit will be kept confidential and used solely to process your application.
Your information will be used to carry out the required Law Enforcement Data Systems Checks (L.E.D.S.) criminal history
background check and sex offender registry check. To complete these checks the following information is needed: date of
birth, driver’s license, expiration date, sex, height, weight, and race.




            Class 40: Revised 2-26-10                                                              Page 29 of 42
                                                                                                  FOR OFFICIAL USE ONLY: CMI
List the name of the YOUTH you wish to mentor                                                     Lead Date
                                                                                                  Recruit Date            Interview Date
_______________________________________________________                                           Background Check Start Date
              (Print Last name, First name)                                                       Background Check End Date
                                                                                                  Reference Check Date #1                        #2
                                                                                                  Screen Date
                                                                                                  Train Date                 Match Date
                                                                                                  Pool/Reserve
                                     PROSPECTIVE MENTOR INFORMATION (complete form in ink)

Last Name____________________________________ First Name __________________________________MI_______
Suffix:    Jr.        Sr.       I       II      III    IV Gender:          Male     Female

How far away (miles) do you live from this youth? ________ Are you related to this youth?                          Yes      No How?________
Ethnicity: Hispanic/Latino YES NO            Race:                              American Indian/Alaskan Native Asian Black/African American
                 For Race please check one or more.                             Native Hawaiian/Other Pacific Islander White

Marital Status:          Divorced              Married       Single    Widowed
How long have you been a resident of the state of Oregon? Year(s) ____ Month(s) _____
Where did you live before moving to Oregon? State_________________________ City___________________________
Driver’s License/ID #_____________________________ State______ Expiration Date (MM/DD/YYYY)______________
Date of Birth: (MM/DD/YYYY)__________________ Age_____ Height: ______FT ______ In. Weight (lbs.)________

Natural Hair Color:              Auburn             Black     Blonde     Brown      Red
Natural Eye Color:              Blue           Brown        Green     Hazel
Contact Lens Eye Color:                      Blue     Brown     Green       Hazel
Appearance/feature(s): (identifying marks, tattoo, scars) i.e. scar/left cheek, tattoo (rose)/right shoulder
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Phone: Home__________________ Work__________________ Ext. _____ Email Address(s):_____________________
          Fax______________________ Cell Phone____________________
When is a good day and time to contact you? (For interview purposes)

Weekday:          Monday              Tuesday          Wednesday        Thursday      Friday              Time_______          AM           PM

What method do you recommend ONGYCP use when contacting you?
            Home Phone                   Work Phone           Cell Phone
Mailing Address___________________________________
          City_______________________ State_________ Zip Code ___________County_____________________
Other Address___________________________________
          City_______________________ State_________ Zip Code ___________County_____________________
Employer Name ___________________________________________Years with Employer_________ Months________
Employer Address___________________________________________________________________________________
                 Street                          City            State                 Zip

Occupation:_________________________________
Employment Status:                  Full Time         Part Time       Retired     Temporary    Unemployed       Volunteer

                 Class 40: Revised 2-26-10                                                                                  Page 30 of 42
                                            List the name of the YOUTH you wish to mentor
                                     _______________________________________________________
                                                    (Print Last name, First name)

PROSPECTIVE MENTOR: Last Name___________________First Name ______________MI______

List three (3) references (one may be a relative)
1. Name________________________________Address__________________________________Zip Code___________
  Home Phone____________________ Work Phone ___________________Cell Phone___________

2. Name________________________________Address__________________________________Zip Code___________
  Home Phone____________________ Work Phone ___________________Cell Phone___________

3. Name________________________________Address__________________________________Zip Code___________
  Home Phone____________________ Work Phone ___________________Cell Phone___________

                                                              What are your…
Interests___________________________________________________________________________________________

Hobbies___________________________________________________________________________________________

Do you have a cultural, or ethnic preference of the youth you wish to mentor?        YES    NO

(what is your preference)?_____________________________________________________________________________
Do you have a personality preference regarding the type of graduate whom you would like to mentor?

(Example: athletic/intellectual)            YES      NO (state your preference) ________________________________________

Is English the primary language you speak?              YES        NO

If NO, what language do you speak: __________________

Do you speak English?              Fluent   Little    Not at all

Have you ever applied before to be a mentor for an ONGYCP Cadet?               YES    NO
If yes please indicate when.________________________________

                                                  MENTOR TRAINING INFORMATION

Mentors must complete a set of on-line training modules prior to attending our on-site mentor training and mentor match
event here at the Oregon National Guard Youth Challenge Program. You can access these modules through our website at
www.oycp.com and follow the links to “MENTORS” and “Mentor training” accordingly. If you have difficulty with our
website, please call 541-317-9623 ext 225 for assistance.

The dates available for our on-site mentor training are listed below. Please check one box for the date you wish to attend.
Please note that this date will be confirmed during your interview with ONGYCP case management staff.

        August 28th, 2010

        September 18th, 2010




             Class 40: Revised 2-26-10                                                                   Page 31 of 42
       MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR

List the name of the YOUTH you wish to mentor
_______________________________________________________
(Print Last name, First name)
                                              Answer the following questions
1.      Have you ever been convicted of a sex-related crime?                                    YES NO
        a. If YES, specify the state and date in which it occurred. State ____________________Date _________
        b. Did the crime involve force and/or minors?                                           YES NO
2.      Do you have a prior history of arrest and conviction for a sex offense?                 YES NO
3.      Have you ever been convicted of a crime involving violence/threat of violence?          YES NO
        If YES, specify the state and date in which occurred. State _____________________Date__________
4.      Do you have a history of physical abuse?                                                YES NO
5.      Do you have a history of domestic violence? (reports, charges, or convictions)          YES NO
        If YES, what was the outcome? ____________________________________________________
6.      Have you ever been convicted of a crime involving drug activity/alcoholic beverages?    YES NO
        If YES specify the state and date in which it occurred. State____________________ Date__________
7.      Do you have a history of alcohol, drug or substance abuse?                                     YES NO
        If YES, how long ago was it resolved?       Less than 5 years         Greater than 5 years     Not Resolved
8.      Have you ever been convicted of a crime, other than a minor traffic violation?  YES NO
        If YES, what was the crime? _____________________ outcome? ___________________________

Have you ever been arrested for a crime for which there has not been an acquittal or a dismissal?      YES         NO
If YES, what was the arrest for? _____________________________ status? ____________________________________

                                         STATEMENT OF CONFIDENTIALLY
Confidentiality is the preservation of privileged information concerning the participant. Most of the information that you
gain about a participant is confidential; in terms of the law, disclosure could make you legally liable, or the disclosure may
violate the trust that the participant has developed with you causing damage to your mentoring relationship.
All records dealing with participants must be treated as confidential.
Before you begin your mentoring assignment, you should be aware of the laws and penalties of breaching confidentiality.
Although ONGYCP may be liable for your action while you are within the scope of your authorized duty, giving
information to an unauthorized person could be interpreted as not acting within the scope of duty, and ONGYCP could
refuse to support you in the event of legal action. Violation of the Oregon Revised Statutes regarding confidentiality of
records is punishable upon conviction by a fine of not more than $1,000 or by imprisonment in the county jail for not more
than 60 days, or both.
                                                         ADVISORY
In order to process this application, the mentor applicant must sign below. A check of references and the applicant’s
criminal history using Law Enforcement Data System (L.E.D.S.) will be made by ONGYCP, law enforcement agencies, or
the Oregon National Guard, to verify the responses on this application. The information listed on this document is used for
background investigation only. ONGYCP does not discriminate on the basis of race, color, creed, sex, age or religion.
I hereby grant to the ONGYCP, law enforcement agencies, or the Oregon National Guard permission to check my
references and civil or criminal records to verify any statement made on this form.
My signature below certifies that I have read, and understood the material above. I understand my duty as a mentor/agent of
the State, to abide by the laws and policies regarding the preservation of confidential information.

Prospective Mentor printed name:___________________________________________________________________

Prospective Mentor signature:____________________________________________Date:______________________

             Class 40: Revised 2-26-10                                                                    Page 32 of 42
                                                    MENTOR REFERENCE #1

This page is to be given to one of the two persons willing to be a reference for you. This reference form is required to
complete your application.
Name of youth to be mentored: ________________________________________________________________________
                                                  (Print – Last name, First name)

Name of person applying to be mentor: __________________________________________________________________
                                                    (Print – Last name, First name)

Name of person giving reference: ______________________________________________________________________
                                                   (Print – Last name, First name)

                                         TO BE COMPLETED BY MENTORS REFERENCE
The person that gave this page to you is applying to be a mentor for a participant of Oregon National Guard Youth
ChalleNGe Program. Please answer the questions on this form as fully and carefully as you can. Information received will
be kept in confidence.

How long have you known the mentor applicant? Years ___ Months ___ Relationship? ___________________
Does the mentor applicant have a good home relationship?       Yes        No
Does the mentor applicant work well with others?        Yes   No
Does the mentor applicant have a tendency to over-commit (get involved with too many things)?          Yes      No
Please rate the mentor applicant as far as the following are concerned:
                                      Excellent            Good                Average        Poor                Unknown
Character……………………...                        _____         _____                 _____          _____                     _____
Morals………………………...                          _____         _____                 _____          _____                     _____
Compassion for those in need...             _____         _____                 _____          _____                     _____
Completes commitments……..                   _____         _____                 _____          _____                     _____
Emotional stability……………                    _____         _____                 _____          _____                     _____
Receives constructive criticism             _____         _____                 _____          _____                     _____
Health…………………………                            _____         _____                 _____          _____                     _____

Other Comments: ___________________________________________________________________________________
__________________________________________________________________________________________________

Would you recommend the mentor applicant as a good choice to work with a teenager? (Explain) ___________________
___________________________________________________________________________________________________
_________________________________________________________________________________________________

Name of Reference ____________________________ Signature ____________________________ Date ____________
Home Phone __________________Work Phone ___________________Ext _________Cell Phone __________________

Upon completion of this form either return it to the mentor applicant OR send/fax it directly to ONGYCP:
Oregon Youth ChalleNGe Program
23861 Dodds Road
Bend, Oregon 97701
Fax: 541-382-6785
Should you have any question(s) feel free to call: 541-317-9623 Ext. 223


             Class 40: Revised 2-26-10                                                                   Page 33 of 42
                                                    MENTOR REFERENCE #2

This page is to be given to one of the two persons willing to be a reference for you. This reference form is required to
complete your application.
Name of youth to be mentored: ________________________________________________________________________
                                                  (Print – Last name, First name)

Name of person applying to be mentor: __________________________________________________________________
                                                    (Print – Last name, First name)

Name of person giving reference: ______________________________________________________________________
                                                   (Print – Last name, First name)

                                         TO BE COMPLETED BY MENTORS REFERENCE
The person that gave this page to you is applying to be a mentor for a participant of Oregon National Guard Youth
ChalleNGe Program. Please answer the questions on this form as fully and carefully as you can. Information received will
be kept in confidence.

How long have you known the mentor applicant? Years ___ Months ___ Relationship? ___________________
Does the mentor applicant have a good home relationship?       Yes        No
Does the mentor applicant work well with others?        Yes   No
Does the mentor applicant have a tendency to over-commit (get involved with too many things)?          Yes      No
Please rate the mentor applicant as far as the following are concerned:
                                      Excellent            Good                Average        Poor                Unknown
Character……………………...                        _____         _____                 _____          _____                     _____
Morals………………………...                          _____         _____                 _____          _____                     _____
Compassion for those in need...             _____         _____                 _____          _____                     _____
Completes commitments……..                   _____         _____                 _____          _____                     _____
Emotional stability……………                    _____         _____                 _____          _____                     _____
Receives constructive criticism             _____         _____                 _____          _____                     _____
Health…………………………                            _____         _____                 _____          _____                     _____

Other Comments: ___________________________________________________________________________________
__________________________________________________________________________________________________

Would you recommend the mentor applicant as a good choice to work with a teenager? (Explain) ___________________
___________________________________________________________________________________________________
_________________________________________________________________________________________________

Name of Reference ____________________________ Signature ____________________________ Date ____________
Home Phone __________________Work Phone ___________________Ext _________Cell Phone __________________

Upon completion of this form either return it to the mentor applicant OR send/fax it directly to ONGYCP:
Oregon Youth ChalleNGe Program
23861 Dodds Road
Bend, Oregon 97701
Fax: 541-382-6785
Should you have any question(s) feel free to call: 541-317-9623 Ext. 223


             Class 40: Revised 2-26-10                                                                   Page 34 of 42
                                    OREGON NATIONAL GUARD
                                   YOUTH CHALLENGE PROGRAM
                                                     23861 DODDS ROAD
                                                    BEND, OREGON 97701
                                                        (541) 317-9623
                                                      FAX (541) 388-9960




                           MENTOR PROGRAM
                         APPLICATION BOOKLET
Participant: Attached are two mentor application booklets. Give one to each of your potential mentors to fill out and
submit.
Mentor Applicant: Complete this application. Participant or Mentor Applicant can mail the application directly to:
                                         Oregon National Guard Youth Challenge Program
                                                     23861 DODDS ROAD
                                                       BEND, OR 97701
                                                         MENTORS
Young people want support. The majority of young people cite parents or other adults as the first source of advice regarding
personal problems. There was a time when our society was made up of extended families and close communities. Aunts,
uncles, cousins and family friends often served naturally as mentors. While families bear the primary obligation to care for
their children and to help them become healthy contributing citizens, other institutions can help families acclimate to a
rapidly changing world. A mentor can provide the nurturing, supportive adult relationship absent in the lives of many of our
young people. Adolescents today are an increasingly isolated population. Changes in the structure of the family,
community, neighborhood relationships and in workplace arrangements have deprived young people of the adult contacts
that historically have been primary sources of socialization and support for development. Many young people lack positive
nurturing and supportive primary adult relationships. A mentor can provide that role, and perhaps more importantly, teach
and guide the young person to find others to fill that role as well. Mentor attributes: maturity, integrity, leadership,
commitment, availability, compatibility and responsibility
                                          ONGYCP Mentor Eligibility Requirements
   An Oregon resident: Currently living in Oregon 12 consecutive months without any break in time.
   Mentor must at least 21 years of age at the date of Mentor Training.
   The mentor and applicant must be the same gender/sex.
   The mentor must be willing to make a 14 month commitment.
   The mentor cannot be an immediate family member or anyone living in the same household as the applicant.
   The mentor is to be within the same geographic proximity as the participant (a distance that is not a travel burden to
    both the mentor/mentee).
   Mentors that are selected are required to complete a set of on-line mentor training modules prior to attending a six hour
    Mentor Training workshop in Bend, Oregon at the program facility: (23861 Dodds RD, Bend OR 97701)
    This training takes place after the youth has begun the program. Please note that all mentor training materials are
    available only in English.
   After completing ONGYCP Residential Phase, the participant and mentor are to have four hours of contacts per month,
    face to face between the mentor and mentee being the preferred method of contact. These contacts take place in the
    respective community of the mentor and participant.




             Class 40: Revised 2-26-10                                                                  Page 35 of 42
                                                  ONGYCP Mentor Disqualifiers
    A history of arrest and conviction for a sex offense
    A felony conviction within last five years
    Any alcohol, drug, substance abuse within last five years
    A history of domestic violence (reports, charges, conviction)
                                                     WHAT IS MENTORING?
Mentoring is a one-to-one relationship over a prolonged period of time between a youth and an adult who provides
consistent support, guidance and concrete help as the younger person may go through a difficult, challenging situation or
period in life. The goal of mentoring is to help youths gain the skills and confidence to be responsible for their own futures.
This includes an increasing emphasis on academic and occupational skills.
                                                Life issues in which mentoring helps

                            Teen pregnancy                           Work or school adjustment
                            Dropout prevention                       Job retention
                            Substance abuse                          Financial management/budgeting
                            Parenting skills                         Educational and career goals
                            Illiteracy                               Home ownership
                            Transition from welfare to work          College preparation
                            Employment preparedness
                                                        ONGYCP Mentoring
The Oregon National Guard Youth Challenge Program is a 17 month program that offers school dropouts an opportunity to
change their futures. The participants will live and work in a controlled, military environment that encourages teamwork
and personal growth. During this time they will work toward achieving their career or educational goals under the guidance
of a volunteer mentor from their home community.
The Oregon National Guard Youth Challenge Program consists of two phases. The first phase is residential, which includes
military structure, discipline, physical development, service to community and academic classroom instruction. The second
phase is the 12 month Post Residential Mentorship Phase.
The mentor relationship begins in the 11th week of the Residential Phase with a Mentor/Mentee Matching Ceremony in
Bend, Oregon. Each mentor is screened and trained prior to meeting with the cadet. From week 11 until the end of the 22
week Residential Phase, the mentor and the mentee correspond by way of letter writing. After the participant graduates you
will be required to contact the mentee at least four hours a month and report back to ONGYCP on a monthly basis.
                                                   ONGYCP MENTOR GOALS
 To seek and train responsible adults to mentor ONGYCP graduates
 Provide the mentors with training and support necessary for a successful mentoring relationship with the graduates
 Assist in creating and maintaining an open network of communication between all parties, to address issues and
  concerns that may arise during the 14 month mentorship
                                       SEQUENCE OF EVENTS FOR A MENTOR
1)    Cadet approaches mentors with applications.
1)   Mentors fill out and submit mentor applications to ONGYCP.
2)   Cadet selects primary and secondary mentors.
3)   Mentors are screened and interviewed by ONGYCP staff. (Mentor training instructions and dates will be scheduled
     during this interview.)
4)   Accepted mentors receive instructions to complete on-line mentor training modules prior to attending mentor training
     workshop and cadet match at ONGYCP facility.
5)   Non-selected mentors will receive a “thank-you for applying” letter.
6)   Mentors are required to correspond weekly with their cadet through letter writing/email during residential weeks 12
     through 22.
7)   Mentors are invited to attend graduation at week 22.
8)   Mentors begin contacts with mentee immediately after graduation for the next 12 months. (This is when the cadet needs
     you the most.) Mentors are required to have 4 hours of contact a month with their mentee, face-to-face being the
     preferred method, and report monthly to ONGYCP staff.

              Class 40: Revised 2-26-10                                                                  Page 36 of 42
                                             HOW CAN ONE APPLY?
A mentor application may be obtained by either visiting the website at www.OYCP.com or calling 541-317-9623 ext. 223.
A criminal background check will be conducted on all mentor candidates prior to being matched to a participant.

COLLECTION AND USE OF INFORMATION BY THE NATIONAL GUARD BUREAU
For purposes of applying as a mentor, you must disclose your personal information to the Oregon National Guard Youth
Challenge Program. The information you submit will be kept confidential and used solely to process your application.
Your information will be used to carry out the required Law Enforcement Data Systems Checks (L.E.D.S.) criminal history
background check and sex offender registry check. To complete these checks the following information is needed: date of
birth, driver’s license, expiration date, sex, height, weight, and race.




            Class 40: Revised 2-26-10                                                              Page 37 of 42
                                                                                                  FOR OFFICIAL USE ONLY: CMI
List the name of the YOUTH you wish to mentor                                                     Lead Date
                                                                                                  Recruit Date            Interview Date
_______________________________________________________                                           Background Check Start Date
              (Print Last name, First name)                                                       Background Check End Date
                                                                                                  Reference Check Date #1                        #2
                                                                                                  Screen Date
                                                                                                  Train Date                 Match Date
                                                                                                  Pool/Reserve
                                     PROSPECTIVE MENTOR INFORMATION (complete form in ink)

Last Name____________________________________ First Name __________________________________MI_______
Suffix:    Jr.        Sr.       I       II      III    IV Gender:          Male     Female

How far away (miles) do you live from this youth? ________ Are you related to this youth?                          Yes      No How?________
Ethnicity: Hispanic/Latino YES NO            Race:                              American Indian/Alaskan Native Asian Black/African American
                 For Race please check one or more.                             Native Hawaiian/Other Pacific Islander White

Marital Status:          Divorced              Married       Single    Widowed
How long have you been a resident of the state of Oregon? Year(s) ____ Month(s) _____
Where did you live before moving to Oregon? State_________________________ City___________________________
Driver’s License/ID #_____________________________ State______ Expiration Date (MM/DD/YYYY)______________
Date of Birth: (MM/DD/YYYY)__________________ Age_____ Height: ______FT ______ In. Weight (lbs.)________

Natural Hair Color:              Auburn             Black     Blonde     Brown      Red
Natural Eye Color:              Blue           Brown        Green     Hazel
Contact Lens Eye Color:                      Blue     Brown     Green       Hazel
Appearance/feature(s): (identifying marks, tattoo, scars) i.e. scar/left cheek, tattoo (rose)/right shoulder
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Phone: Home__________________ Work__________________ Ext. _____ Email Address(s):_____________________
          Fax______________________ Cell Phone____________________
When is a good day and time to contact you? (For interview purposes)

Weekday:          Monday              Tuesday          Wednesday        Thursday      Friday              Time_______          AM           PM

What method do you recommend ONGYCP use when contacting you?
            Home Phone                   Work Phone           Cell Phone
Mailing Address___________________________________
          City_______________________ State_________ Zip Code ___________County_____________________
Other Address___________________________________
          City_______________________ State_________ Zip Code ___________County_____________________
Employer Name ___________________________________________Years with Employer_________ Months________
Employer Address___________________________________________________________________________________
                 Street                          City            State                 Zip

Occupation:_________________________________
Employment Status:                  Full Time         Part Time       Retired     Temporary    Unemployed       Volunteer

                 Class 40: Revised 2-26-10                                                                                  Page 38 of 42
                                            List the name of the YOUTH you wish to mentor
                                     _______________________________________________________
                                                    (Print Last name, First name)

PROSPECTIVE MENTOR: Last Name___________________First Name ______________MI______

List three (3) references (one may be a relative)
1. Name________________________________Address__________________________________Zip Code___________
  Home Phone____________________ Work Phone ___________________Cell Phone___________

2. Name________________________________Address__________________________________Zip Code___________
  Home Phone____________________ Work Phone ___________________Cell Phone___________

3. Name________________________________Address__________________________________Zip Code___________
  Home Phone____________________ Work Phone ___________________Cell Phone___________

                                                              What are your…
Interests___________________________________________________________________________________________

Hobbies___________________________________________________________________________________________

Do you have a cultural, or ethnic preference of the youth you wish to mentor?        YES    NO

(what is your preference)?_____________________________________________________________________________
Do you have a personality preference regarding the type of graduate whom you would like to mentor?

(Example: athletic/intellectual)            YES      NO (state your preference) ________________________________________

Is English the primary language you speak?              YES        NO

If NO, what language do you speak: __________________

Do you speak English?              Fluent   Little    Not at all

Have you ever applied before to be a mentor for an ONGYCP Cadet?               YES    NO
If yes please indicate when.________________________________

                                                  MENTOR TRAINING INFORMATION

Mentors must complete a set of on-line training modules prior to attending our on-site mentor training and mentor match
event here at the Oregon National Guard Youth Challenge Program. You can access these modules through our website at
www.oycp.com and follow the links to “MENTORS” and “Mentor training” accordingly. If you have difficulty with our
website, please call 541-317-9623 ext 225 for assistance.

The dates available for our on-site mentor training are listed below. Please check one box for the date you wish to attend.
Please note that this date will be confirmed during your interview with ONGYCP case management staff.

        August 28th, 2010

        September 18th, 2010




             Class 40: Revised 2-26-10                                                                   Page 39 of 42
       MENTOR APPLICATION (Continued) TO BE COMPLETED BY THE PROSPECTIVE MENTOR

List the name of the YOUTH you wish to mentor
_______________________________________________________
(Print Last name, First name)
                                              Answer the following questions
1.      Have you ever been convicted of a sex-related crime?                                    YES NO
        a. If YES, specify the state and date in which it occurred. State ____________________Date _________
        b. Did the crime involve force and/or minors?                                           YES NO
2.      Do you have a prior history of arrest and conviction for a sex offense?                 YES NO
3.      Have you ever been convicted of a crime involving violence/threat of violence?          YES NO
        If YES, specify the state and date in which occurred. State _____________________Date__________
4.      Do you have a history of physical abuse?                                                YES NO
5.      Do you have a history of domestic violence? (reports, charges, or convictions)          YES NO
        If YES, what was the outcome? ____________________________________________________
6.      Have you ever been convicted of a crime involving drug activity/alcoholic beverages?    YES NO
        If YES specify the state and date in which it occurred. State____________________ Date__________
7.      Do you have a history of alcohol, drug or substance abuse?                                     YES NO
        If YES, how long ago was it resolved?       Less than 5 years         Greater than 5 years     Not Resolved
8.      Have you ever been convicted of a crime, other than a minor traffic violation?  YES NO
        If YES, what was the crime? _____________________ outcome? ___________________________

Have you ever been arrested for a crime for which there has not been an acquittal or a dismissal?      YES         NO
If YES, what was the arrest for? _____________________________ status? ____________________________________

                                         STATEMENT OF CONFIDENTIALLY
Confidentiality is the preservation of privileged information concerning the participant. Most of the information that you
gain about a participant is confidential; in terms of the law, disclosure could make you legally liable, or the disclosure may
violate the trust that the participant has developed with you causing damage to your mentoring relationship.
All records dealing with participants must be treated as confidential.
Before you begin your mentoring assignment, you should be aware of the laws and penalties of breaching confidentiality.
Although ONGYCP may be liable for your action while you are within the scope of your authorized duty, giving
information to an unauthorized person could be interpreted as not acting within the scope of duty, and ONGYCP could
refuse to support you in the event of legal action. Violation of the Oregon Revised Statutes regarding confidentiality of
records is punishable upon conviction by a fine of not more than $1,000 or by imprisonment in the county jail for not more
than 60 days, or both.
                                                         ADVISORY
In order to process this application, the mentor applicant must sign below. A check of references and the applicant’s
criminal history using Law Enforcement Data System (L.E.D.S.) will be made by ONGYCP, law enforcement agencies, or
the Oregon National Guard, to verify the responses on this application. The information listed on this document is used for
background investigation only. ONGYCP does not discriminate on the basis of race, color, creed, sex, age or religion.
I hereby grant to the ONGYCP, law enforcement agencies, or the Oregon National Guard permission to check my
references and civil or criminal records to verify any statement made on this form.
My signature below certifies that I have read, and understood the material above. I understand my duty as a mentor/agent of
the State, to abide by the laws and policies regarding the preservation of confidential information.

Prospective Mentor printed name:___________________________________________________________________

Prospective Mentor signature:____________________________________________Date:______________________

             Class 40: Revised 2-26-10                                                                    Page 40 of 42
                                                    MENTOR REFERENCE #1

This page is to be given to one of the two persons willing to be a reference for you. This reference form is required to
complete your application.
Name of youth to be mentored: ________________________________________________________________________
                                                  (Print – Last name, First name)

Name of person applying to be mentor: __________________________________________________________________
                                                    (Print – Last name, First name)

Name of person giving reference: ______________________________________________________________________
                                                   (Print – Last name, First name)

                                         TO BE COMPLETED BY MENTORS REFERENCE
The person that gave this page to you is applying to be a mentor for a participant of Oregon National Guard Youth
ChalleNGe Program. Please answer the questions on this form as fully and carefully as you can. Information received will
be kept in confidence.

How long have you known the mentor applicant? Years ___ Months ___ Relationship? ___________________
Does the mentor applicant have a good home relationship?       Yes        No
Does the mentor applicant work well with others?        Yes   No
Does the mentor applicant have a tendency to over-commit (get involved with too many things)?          Yes      No
Please rate the mentor applicant as far as the following are concerned:
                                      Excellent            Good                Average        Poor                Unknown
Character……………………...                        _____         _____                 _____          _____                     _____
Morals………………………...                          _____         _____                 _____          _____                     _____
Compassion for those in need...             _____         _____                 _____          _____                     _____
Completes commitments……..                   _____         _____                 _____          _____                     _____
Emotional stability……………                    _____         _____                 _____          _____                     _____
Receives constructive criticism             _____         _____                 _____          _____                     _____
Health…………………………                            _____         _____                 _____          _____                     _____

Other Comments: ___________________________________________________________________________________
__________________________________________________________________________________________________

Would you recommend the mentor applicant as a good choice to work with a teenager? (Explain) ___________________
___________________________________________________________________________________________________
_________________________________________________________________________________________________

Name of Reference ____________________________ Signature ____________________________ Date ____________
Home Phone __________________Work Phone ___________________Ext _________Cell Phone __________________

Upon completion of this form either return it to the mentor applicant OR send/fax it directly to ONGYCP:
Oregon Youth ChalleNGe Program
23861 Dodds Road
Bend, Oregon 97701
Fax: 541-382-6785
Should you have any question(s) feel free to call: 541-317-9623 Ext. 223


             Class 40: Revised 2-26-10                                                                   Page 41 of 42
                                                    MENTOR REFERENCE #2

This page is to be given to one of the two persons willing to be a reference for you. This reference form is required to
complete your application.
Name of youth to be mentored: ________________________________________________________________________
                                                  (Print – Last name, First name)

Name of person applying to be mentor: __________________________________________________________________
                                                    (Print – Last name, First name)

Name of person giving reference: ______________________________________________________________________
                                                   (Print – Last name, First name)

                                         TO BE COMPLETED BY MENTORS REFERENCE
The person that gave this page to you is applying to be a mentor for a participant of Oregon National Guard Youth
ChalleNGe Program. Please answer the questions on this form as fully and carefully as you can. Information received will
be kept in confidence.

How long have you known the mentor applicant? Years ___ Months ___ Relationship? ___________________
Does the mentor applicant have a good home relationship?       Yes        No
Does the mentor applicant work well with others?        Yes   No
Does the mentor applicant have a tendency to over-commit (get involved with too many things)?          Yes      No
Please rate the mentor applicant as far as the following are concerned:
                                      Excellent            Good                Average        Poor                Unknown
Character……………………...                        _____         _____                 _____          _____                     _____
Morals………………………...                          _____         _____                 _____          _____                     _____
Compassion for those in need...             _____         _____                 _____          _____                     _____
Completes commitments……..                   _____         _____                 _____          _____                     _____
Emotional stability……………                    _____         _____                 _____          _____                     _____
Receives constructive criticism             _____         _____                 _____          _____                     _____
Health…………………………                            _____         _____                 _____          _____                     _____

Other Comments: ___________________________________________________________________________________
__________________________________________________________________________________________________

Would you recommend the mentor applicant as a good choice to work with a teenager? (Explain) ___________________
___________________________________________________________________________________________________
_________________________________________________________________________________________________

Name of Reference ____________________________ Signature ____________________________ Date ____________
Home Phone __________________Work Phone ___________________Ext _________Cell Phone __________________

Upon completion of this form either return it to the mentor applicant OR send/fax it directly to ONGYCP:
Oregon Youth ChalleNGe Program
23861 Dodds Road
Bend, Oregon 97701
Fax: 541-382-6785
Should you have any question(s) feel free to call: 541-317-9623 Ext. 223


             Class 40: Revised 2-26-10                                                                   Page 42 of 42

				
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