AMP! Returning Mentor Application for 2019/20 School Year
Thank you for completing this application for the AMP! Metro Richmond (AMP!) Mentoring Program at T.C. Boushall Middle School (3400 Hopkins Rd, Richmond, VA 23234) for the 2019-2020 school year. This application is for those who have mentored with us in the last 2 years. Submitting your application expresses your interest in mentoring with our organization. This year mentoring will occur on Tuesdays from 11:30-12:30. This usually includes about 10 weeks during the Fall of 2019 and 15 weeks during Spring of 2020. Please know that AMP! and Boushall Middle School will keep all information on this application in confidence and will use it solely for purposes of this program.
Personal Information
Name *
(First and Last)
Address *
**Please include full address with city and zip code. This is important for background checks!**
Cell Phone *
Birth Date *
Gender *
Ethnicity *
Preferred Email for Communications *
Best way to get in touch with you in case of last minute changes on mentoring days. *
Employment Information
Employer *
Work Phone *
Position in your Organization *
Length of Time in Position *
Application Questions
Please answer the following questions as completely as possible. AMP! and Boushall will use your responses to match you with your mentee.
Can you commit to participate in the AMP! Metro Richmond mentoring program for the entire 2019-2020 school year? *
Please list any dates from Oct -April where you could have a conflict and may NOT be able to attend mentoring. The mentoring time will be around lunchtime on Tuesdays. *
Our policy is that you miss no more than 2 dates per semester. Once we see your availability, we will let you know if it is still possible for you to participate.
Are you willing to communicate regularly and openly with program staff, provide feedback regarding your mentoring activities, and receive feedback regarding any difficulties during your participation in the mentoring program? *
This includes an end of year survey.
Please read this carefully before signing
AMP! Metro Richmond appreciates your interest in becoming a mentor. Please type your initials for each of the following:
I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship. *
I understand that AMP! and Richmond Public Schools (RPS) are not obligated to provide a reason for their decision in accepting or rejecting me as a mentor. *
I agree to communicate regularly and openly with program staff, provide information regarding my mentoring activities, and receive feedback regarding any difficulties during my participation in the mentoring program. *
I agree to allow AMP! and RPS to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotions, newsletters, and/or other related marketing materials.
I understand that this program takes place on school property and during school hours or on AMP!-sponsored field trips. Any separate activities I choose to do with RPS are not part of the AMP! mentoring program. Any separate activities I choose to do with the student I am mentoring are not part of AMP!'s mentoring program and require permission from the student's parent or guardian. *
I understand AMP! requires a background screening through First Advantage for all participating mentors. The background check will include criminal history and personal references. *
AMP! will begin that process after volunteers commit to mentoring by attending an AMP! Orientation and Training session. AMP! will incur costs related to background screening.
Prior to that background process, please answer yes or no to the following. *
Have you ever been arrested, convicted, or pled guilty or "no contest" to ANY offense other than a minor traffic offense in a court of law?
Have you ever been convicted of ANY sex, alcohol, or drug related offense?
Have you ever been convicted of ANY dangerous crime against children?
Have you ever been investigated or convicted in a case involving the physical or sexual abuse of a child (age 18 or younger)?
Are any criminal charges or proceedings pending against you?
If you answered "Yes" to ANY questions above, explain.
Note: For criminal charges, specify all of the charge(s), date(s), disposition(s), name(s), and address(es) of the court(s) and judgement(s) or conviction(s). (CONVICTION means the final judgement on a verdict or a finding of guilty, or plea of nolo contendere, in any state or federal court of competent jurisdiction in a criminal case, regardless of whether an appeal is pending or could be taken. Conviction does not include a final judgment which has been expunged by pardon, reversed, set aside, or otherwise rendered invalid.)
Please type your name below, and your typed name attests that you agree to abide by the program guidelines and that all information in this document is accurate to the best of your knowledge. *
Mentor Interest Survey
Please complete all of the following. This survey will help AMP! know more about you and your interests and help us find the best match for you.
Do you speak any languages other than English? If so, which languages? *
Is there a specific type of student you feel you would work with best? *
Gender, personality, interests, etc? If you are a returning mentor, you can comment here if you feel you should or should not be matched with the same mentee as last year.
Would you be willing to work with a child who has disabilities? If so, please specify disabilities you would be willing to work with. *
Is there any other information you would like us to know about yourself?
Referrals are the best way we find mentors! Can you refer a friend, relative or co-worker who may be interested in mentoring with our program?
Please list their name, phone number and email address.
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