Mentor Application Form

Thank you for your interest in becoming a mentor with the Mentoring Program. Please complete the following form to apply. First Name Last Name Birth Date Gender Street Address City Province Postal Code Phone Email I prefer to work with a child in: Middle School (Gr. 6-8)High School (Gr. 9-12) Please write a brief statement on why you wish to be a mentor: What is your availability? Are you able to commit to spending 2 hours per week with your mentee for at least a year? What are some of your interests or hobbies? This information is helpful when matching you with your mentee. Do you have any experience being a mentor or personal experience that has prepared you for this role? (teaching, coaching, working with youth, etc?) How do you envision supporting your mentee's growth and development? How do you think you could help the mentee build skills, confidence and resilience? You will be expected to write a brief mentor report monthly for The Center to document as well as have periodic check-ins with the Program Administrator. Do you have any hesitations with this expectation? Please provide 3 references (non-family members): First Reference Name First Reference Phone First Reference Email Relationship to Reference Second Reference Name Second Reference Phone Second Reference Email Relationship to Reference Third Reference Name Third Reference Phone Third Reference Email Relationship to Reference How did you hear about the Centered Mentoring Program? Are you able to provide your drivers license, vehicle insurance and driving abstract for us to have on file? If not, please explain Do you agree to supply The Center with a criminal record and vulnerable sector check as part of the screening process for the mentoring program?

Mentor Release Statement

(adapted from Foundations of Successful Youth Mentoring sample statement)

I, the undersigned, hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of the Swift Current Community Youth Initiative Mentoring Program.

I understand that I will complete orientation training before the mentoring relationship can begin.

I agree to have an open mind as I engage in a supportive relationship with the mentee and I agree to notify the Program Administrator if I am having difficulty connecting and building a relationship with my assigned mentee.

I understand that there might not be a compatible mentee on The Center waitlist, at which point I may be asked to wait until a youth with the right qualifications applies.

I am willing to commit to 2 hours/week for at least one year in the program at which point I may be asked to renew for another year.

I agree to refrain from contacting or seeing my mentee outside of the established parameters of mentoring sessions unless otherwise directed.

I agree to notify the Program Administrator of any changes to my address and telephone number.

I will ensure confidentiality in carrying out the duties assigned to me as a volunteer/staff. Except as I may be legally required, I will not disclose or give to any person not employed by, or functioning in an employee role, or a volunteer of The Center, any information or document of a confidential nature that comes to my knowledge or possession while performing these duties.

I have not been convicted within the past 10 years, of any felony or misdemeanour classified as an offence against a person or family related to any offences of the violent or sexual nature, of public indecency, or a violation involving a controlled substance. I am not under current indictment.

Further, I hereby release, discharge, and hold harmless the Swift Current Community Youth Initiative Mentoring Program, participating organizations, and all of the foregoing employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs and expenses which may be or may at any time hereafter become attributable to my participation in the Swift Current Community Youth Initiative Mentoring Program.

I understand that the Swift Current Community Youth Initiative staff reserves the right to terminate a mentor from the program. The program takes place within the confines of the program’s policies and does not encourage or approve of relationships established between mentor/mentee and family members beyond the organized and supervised activities of the program.

I understand that the Swift Current Community Youth Initiative holds the right to complete a home safety check in my home if necessary. This includes verification of personal and employment references.

Program staff has final right of acceptance of an applicant into the program and reserves the right to terminate a mentor from the program at any time.

I have read the above release statement and by continuing, agree to the contents. By continuing I certify that all statements in this application are true and accurate.

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