Returning Mentor Application for 2024/25 School Year
Thank you for completing this application for the AMP! Metro Richmond (AMP!) Mentoring Program for students at T.C. Boushall Middle School for the 2024-2025 school year.  This application is for those who have mentored with us in the last 2 years.  Matches will all meet in the same room together on the same day and time. 

The time commitment for mentoring is always 1 hour for 1 day a week when school is in session.  Mentoring this school year will occur on Tuesdays from 1:15-2:15pm.  The mentoring year will typically include about 10 weeks during the Fall of 2024 and 15 weeks during Spring of 2025.

Submitting your application expresses your interest in mentoring with our organization.  AMP! program staff will be in touch regarding next steps.  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.
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Personal Information
Full Legal Name *
(First and Last)
Preferred Name or Nickname
Address *
Please include full address with city and zip code.
Cell Phone *
Birth Date *
MM
/
DD
/
YYYY
Gender *
Race *
Required
Preferred Email for Communications *
Best way to get in touch with you in case of last minute changes on mentoring days. *
Employment Information
Employer *
If you are a college student, you can list your college here.
Work Phone
Position in your Organization *
College students can list "student".
Length of Time in Position *
College students, please list your year.
Application Questions
Please answer the following questions as completely as possible.  AMP! and Boushall will use your responses to best match you with your mentee.
Can you commit to participate in the AMP! Metro Richmond mentoring program for the entire 2024-2025 school year? *
Are you available on Tuesdays from 1:15-2:15pm to mentor?
 *
Please list any Tuesday dates from Sept -April  where you could have a conflict and may NOT be able to attend mentoring.   *
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.
Optional
I understand that this program takes place as a group and is monitored by the program coordinator.  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 every 3 years through Sterling Volunteers 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 the New Mentor Training session.  Volunteers have the option to help cover part or all ($39) of background check costs.  If a mentor is unable to, AMP! will cover the costs related to background screening. A separate email will be sent out when we are ready to complete the background check.
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.)
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. *
What are your hobbies and what do you like to do in your free time? *
How would you describe your life when you were in middle school?  What kinds of activities were you involved in?
 *
Is there any other information you would like us to know about yourself?
Do you need any special accomodations or assistance to participate in this program?  If so, please describe below.
Referrals are the best way we find mentors!  If you have a friend, relative or co-worker who may be interested in mentoring with our program, please refer them below.
Please list their name, phone number and email address.
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