AMP! Mentor Application for 2017-2018 School Year
Thank you for completing this application for the AMP! Metro Richmond (AMP!) Mentoring Program at Henderson Middle School (4319 Old Brook Road) for the 2017-2018 school year. Submitting your application expresses your interest in mentoring with our organization. This year, you will have the option to choose from two different mentoring days to suit your schedule. Choose from either Tuesdays or Thursdays from 11:30-12:24pm. This usually includes about 10 weeks during the Fall of 2017 and 15 weeks during Spring of 2018. Please know that AMP! and Henderson 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)
Your answer
Address
**Please include full address with city and zip code. This is important for background checks!**
Your answer
Cell Phone
Your answer
Birth Date
MM
/
DD
/
YYYY
Gender
Ethnicity
Social Security Number
Needed for background checks, which are done on each mentor every 3 years. We will delete this from our system once we complete this. If you are not comfortable putting it on this form, we will need to get it from you via phone or in person. Please do not include the dashes.
Your answer
Preferred Email for Communications
Your answer
Best way to get in touch with you in case of last minute changes on mentoring days.
Employment Information
Employer
Your answer
Work Phone
Your answer
Position in your Organization
Your answer
Length of Time in Position
Your answer
Application Questions
Please answer the following questions as completely as possible. AMP! and Henderson will use your responses to match you with your mentee.
Why do you want to become a mentor in this program?
Your answer
Do you have any previous experience mentoring, volunteering or working with youth? If so, please specify.
Your answer
What qualities, skills, or other attributes do you feel you have that would benefit a middle school-aged student? Please explain.
Your answer
Can you commit to participate in the AMP! Metro Richmond mentoring program for the entire 2017-2018 school year?
Which day(s) is better for you to mentor?
Mentoring will be from 11:30-12:24pm. We could use some more mentors in the Thursday slot. Check all days that will work for you.
Required
Please list any dates from Oct 10-April 26 where you could have a conflict and may NOT be able to attend mentoring. The mentoring time will be from 11:30-12:24pm on either Tuesday or Thursday depending on which day you pick.
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.
Your answer
Are you willing to attend the mandatory initial 2.5 hr mentor training session held by Virginia Mentoring Partnership (VMP)? **UR students, your orientation will be conducted through The Bonner Center.
This is only mandatory for new mentors. Please check VMP's training schedule and pick a date that works for you, preferably as soon as possible. Visit https://vamentoring.org/what-we-do/training/ and sign up for the new mentor training that works for your schedule. Use promotion code 'AMP2017' when signing up so you are not charged. Please let us know which date you have signed up for.
How would you describe yourself as a person?
Please include two things you would like your mentee to know about you.
Your answer
How would your friends, family, and co-workers describe you?
Your answer
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.
Your answer
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.
Your answer
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.
Your answer
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.
Optional
Your answer
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.
Your answer
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.
Your answer
Prior to that background process, please answer yes or no to the following.
Yes
No
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.)
Your answer
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.
Your answer
Personal References
**Returning mentors can skip this section.
Please list the names and phone numbers of two people you would like to use as character references (only people you have known for at least a year and are non-family members). Any information AMP! gathers from these references will be held as confidential and not released to you, the applicant.
Name
Your answer
Phone
Your answer
Relationship
Your answer
How long known
Your answer
Name
Your answer
Phone
Your answer
Relationship
Your answer
How long known
Your answer
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?
Your answer
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 not be matched with the same mentee as last year.
Your answer
Would you be willing to work with a child who has disabilities? If so, please specify disabilities you would be willing to work with.
Your answer
What are some favorite things you like to do with other people?
Your answer
What are your favorite subjects to read/learn about?
Your answer
What is your job and how did you choose this field?
Your answer
What is one goal you have set for the future?
Your answer
If you could learn something new, what would it be?
Your answer
What person do you most admire and why?
Your answer
Describe your ideal Saturday.
Your answer
What are your hobbies and interests?
Your answer
Is there any other information you would like us to know about yourself?
Your answer
How did you hear about AMP!?
Your answer
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.
Your answer
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