Mentor Application
A Professional Development Workshop Series
First Name:
Your answer
Last Name:
Your answer
Birth Date:
Your answer
Phone Number:
Your answer
Your answer
Emergency Contact Name & Phone:
Your answer
Emergency Contact Email:
Your answer
Are you currently in school?
If so, please name school:
Your answer
Are you currently employed?
If so, please name job
Your answer
Please describe your educational background
Your answer
Have you worked with individuals with disabilities? If so, describe your experience.
Your answer
Why are you interested in being a mentor?
Your answer
Do you have previous experience being a mentor? If so, describe your experience.
Your answer
Why are you interested in “Your Path To Success”?
Your answer
What is your experience with problem solving?
Your answer
What do you hope to gain out of being a mentor in this program?
Your answer
What are three of your goals as a mentor in this program?
Your answer
What impact do you hope to impart on the mentees?
Your answer
What expert qualifications do you have that you believe can help add to the program?
Your answer
Do you have any questions about your role as a mentor or about the program?
Your answer
Program Itinerary (January - March 2018)
January 7th or January 8th Mentor Training
Jan 21st 11AM – 1PM: Removing Labels & Goal Setting (with WUSA9’s Debra Alfarone)
Jan 29th 6:30 – 8:30PM: Digital Communication Skills – Basic Computer
Feb 4th 12PM – 2:30PM: Communication Skills
Feb 11th 10AM – 1PM: Group community service project off-site
BREAK For President’s Day (Makeup Week if there is a weather cancellation)
Feb 26th 6:30 – 8:30PM: Career Search (with Brooklyn Boulders’ Amy Rishko)
March 5th 6:30 – 8:30PM: Resume Building (with Hire Strategy’s Daniel Silverman)
March 11th – March 17th: Networking Event (with Entrypoint)
March 1st – March 18th: Off-site job visits
March 18th 11AM – 2PM: Lunch & Debrief from Job Site Visits | Learning the interview process
March 25th 11AM - 2PM: Mock interviews and final party
Goals of Your Path To Success:
• 5 participants (mentees) and 5 volunteers (mentors)
• Mentee to create professional resume
• Mentee to apply to two jobs
• Mentee to participate in mock interview
Objectives for Mentees/Participants:
• Develop a trusted relationship between mentors and mentees
• Increase communication skills (verbal, digital)
• Increase networking skills and social engagement
Objectives for Mentors/Volunteers:
• Develop a trusted relationship between mentors and mentees
• Help Mentees achieve objectives
• To help mentees connect with other peers (mentors and mentees) in a meaningful, positive way
• To assist the student in personal assessment of his/her abilities and support their transition academically, socially, and personally
Criteria & Expectations for Mentors:
• Interview with a program representative
• Attend all workshop sessions and January training session
• Appropriate communication/contact with Mentee
• Inclusivity
• Set positive examples for others in personal, academic, and social behaviour
• Become acquainted with all mentees and mentors in the group and establish positive relationships; promote mentee/mentor interaction
• Be aware of mentee’s attitudes and be sensitive to individual as well as group needs
• Encourage a sense of individual responsibility within mentee
• Proactive follow up with mentee
• Fill out post workshop evaluations
• After any unsupervised (non-group) meeting, complete Meeting Review document
• Coordinating own transportation for meetings
In submitting this application, please agree to the following statements by checking them: I, _____________________________declare that: *
Your answer
I understand the objectives and goals for the program, and both the mentor and mentees, and will strive to help achieve those goals.
I will attend all workshop sessions and pre-program mentor training session. If I must miss a session, I will email 24 – 48 hours in advance to inform Glenda or Stacey of my absence and will do due diligence to makeup the session with my mentee.
I agree to a background check.
I have never been convicted of a misdemeanor, felony, or crime.
I agree to taking a pre-program survey, intermediate survey, and post program survey; as well as, filling out post workshop evaluations.
I understand that there are inherent risks involved with the program
I have read and understood the program itinerary and mentor criteria
The information contained in this application form and supporting documents that I have provided to Dreams For Kids DC and Edlavitch JCC is true and correct
I understand providing false or misleading information is a serious offense.
I agree to the above statements. Please sign your name. *
Your answer
Privacy Policy
The information provided will be used only for the internal purpose of an assessment by Dreams For Kids DC (DFKDC). The information in this application may be confidential and may be legally privileged. It is intended solely for DFKDC use. Some information may be utilized for evaluation before, during, and upon completion of the program for assessment needs – your name will be confidential. If you are not the intended recipient hereof, any disclosure, copying, distribution or any action taken or omitted to be taken in reliance of this document is prohibited and may be unlawful.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms