2019-2020 CCDI Mentor Interest Application
Please fill out the top portion of required information. The bottom half is recommended, but not required.
Email address *
REQUIRED INFORMATION
First & Last Name *
Your answer
Place of Employment *
Your answer
Job Title *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Cell Phone Number *
Your answer
Mailing Address *
Your answer
MENTOR BACKGROUND QUESTIONS (Optional)
Please feel free to complete the following questions at your convenience. You do not have to answer every question.
Gender
Your answer
Ethnicity
Your answer
Are you bilingual? Indicate Languages/ Written/ Spoken
Your answer
What are your interests, hobbies, activities you do for fun?
Your answer
Please give brief overview of your career background, what your areas of expertise are, and personal strengthens you could provide a mentee.
Your answer
BECOMING A CCDI MENTOR (Required)
Please briefly explain why you would like to become a mentor for CCDI. *
Your answer
Have you ever worked with children, young adults, or previously been a mentor?
Which age group would you prefer for a mentee? (check all that apply)
What mentor or coach pathway are you most interested in? (check all that apply) *
Required
MENTOR REQUIREMENTS & EXPECTATIONS
Attend an initial mentor training session and other mentor-mentee events after being matched.
Have your name ran through a criminal record check. (A MO/IL background check application will be emailed to you) *
Commit to trying to meet with your mentee once a month and/or staying in communication with them on a regular basis for a minimum of one year.
Assist with transportation for your mentee to attend CCDI events, specifically Saturday Academy sessions. (Not required, but appreciated)
Valid driver's license and insurance. If selected, you will be asked to provide a copy of each.
FEEDBACK (Optional)
Please check out our website www.ccdi.org and on our social media pages @ccdicommunity
How did you hear about the CCDI program?
Your answer
Additional Comments or Questions?
Your answer
Thank you so much for expressing interest in becoming a CCDI mentor! We will be in touch with you soon!
Please contact Rachel Boemer at RachelBoemer@ccdi.org for immediate questions or Mentorship Committee Chairs Dan Lester at LesterD@claycorp.com or Branyea Jones at JonesBr@claycorp.com
A copy of your responses will be emailed to the address you provided.
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