Note: We respect your privacy and will not share your information with anyone.
 - Denotes a Required Field
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| PERSONAL INFORMATION |
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First Name:
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Middle Name:
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Last Name:
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Home Address:
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City:
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State: Zip:
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Home Phone w/Area Code:
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Work Phone w/Area Code:
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Cell Phone:
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Email:
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Fax Number:
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Employer:
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Job Title:
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Work Address:
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City:
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State: Zip:
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Emergency Contact:
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Home Phone:
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Work Phone:
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| BACKGROUND INFORMATION |
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What product or services does your company provide?
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Describe your job duties.
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Please list other volunteer organizations or services groups in which you participate.
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Please list your hobbies, skills and interests.
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Please list other careers your have had and your educational background.
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What is your gender?
Male
Female |
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Please indicate your racial/ethnic group(s). You may check all that apply.
Asian/Pacific Islander
Hispanic
African American
Native American
Middle Eastern
White (Non-Latino)
Other
I would prefer not to answer this |
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Do you have children?
Yes
No
If so, what are their ages?
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Please list any languages you speak other than English.
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Have you ever been terminated or otherwise disciplined, placed on probation, or warned not to continue engaging in certain conduct while volunteering with any agency? If so, please explain.
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Please check your age group.
18-23 years old
24 years or older |
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Can you mentor during the work day (8am-3pm)?
Yes
No |
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What times will you be available to mentor?
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In which program will you be interested in participating in? You may check all that apply.
Harper Woods
Southfield (potential school)
Warren
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Can you start conversations when in a group?
Yes
No |
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How would you describe yourself?
Introverted
Extroverted |
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Are you comfortable sharing personal stories with a diverse group of students?
Yes
No |
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Have you had recent dealings with teenagers?
Yes
No |
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May we publish your address, phone number and email address in the Mentor Directory?
Yes
No |
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Do you agree to keep all information about other mentors and your students confidential?
Yes
No |
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May we use photos of you for marketing purposes (newsletters, recruitment display, etc.)?
Yes
No |
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Do you agree to meet with your team every session and arrive on time?
Yes
No |
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If you need to miss a session, do you agree to send someone to work with your team?
Yes
No |
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Will you coach and encourage your team to complete their weekly assignments?
Yes
No |
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With your students, will you act at all times to accomplish the mission of the program?
Yes
No |
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Do you agree to write/email your students at least twice per month for an entire year?
Yes
No |
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Do you agree to bring in resources specific to your student's schooling and career interests?
Yes
No |
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Do you agree to send the parents an introductory letter about yourself?
Yes
No |
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Do you agree to attend the mandatory three hour mentor training?
Yes
No |
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Do you agree that you will NOT meet your students outside of the program unless the students' parents give permission in writing to meet in a public group setting?
Yes
No |
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Do you agree that you will NOT transport your students unless you have permission?
Yes
No |
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Do you understand that Winning Futures is not liable for any interactions you have with our students outside of the program?
Yes
No |
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Do you agree to abide by mentoring rules?
Yes
No |
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Do you agree to have a State of Michigan Criminal Background Check completed?
Yes
No |
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Do you agree to have an FBI Fingerprint Check completed?
Yes
No |
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Do you agree to have a Department of Human Services Registry Clearance completed?
Yes
No |
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How certain are you that you can fulfill your time commitment as a mentor for the duration of the program?
Very Sure
Sure
Somewhat Sure
Unsure |
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How did you initially find out about the mentoring program?
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Please list additional comments, concerns or preferences you may have below.
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State of Michigan Background Check Authorization Form It is the policy of our organization to secure criminal conviction history information as part of the volunteer screening process using the information provided below.
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Last Name:
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First Name:
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Middle Name:
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Maiden Name / Names Previously Used:
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Date of Birth:
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Gender:
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Race:
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I understand that the above information is required by the Central Records division of the Michigan State Police, Lansing, MI. I authorize Mentoring Solutions to utilize the above information for the sole purpose of obtaining a conviction only criminal history file search. I verify that the above information is complete and true. I understand that the agency is not obligated to assign me or continue my assignment if, in their professional judgment, it would not be in the best interest of myself or the persons served by the agency.
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Signature of Applicant:
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Date:
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Note: Please type in your name as your signature and we will have you sign it at your interview. |
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