Mentor Application

JAMESON CAMP

Mentor Application

2001 Bridgeport Road

Indianapolis, IN 46231

317-241-2661 x14

Fax: 317-241-2762

E-mail:

Website: www.jamesoncamp.org

PERSONAL INFORMATION

______

Last Name First Name Middle Initial

______

Home Address City State Zip

______

Home Phone Work Phone E-mail Address

______

Social Sec. # Date of Birth Gender

Preferred Method of Contact: ______

Race: _____ Asian Pacific Islander _____ African-American _____ Caucasian

_____ Hispanic/Latino _____ Multi-Racial _____ Native American

_____ Other: ______

Languages Spoken: _____ English _____ Spanish _____ Other: ______

Marital Status: _____ Single _____ Divorced _____ Domestic Partnership

_____ Separated _____ Widowed

_____ Married (spouse’s name) ______

Do you have children? ______yes ______no If yes, how old and what gender are they ? ______

If yes, please describe:______

______

(A “yes” answer does not automatically disqualify you from being a mentor. Upon receiving the information, all details will be considered.)

WORK HISTORY

Please list the three most recent jobs you have held. (Resume can be attached in lieu of this section)

EDUCATION

Please list the most recently attended school first.

LICENSES AND CERTIFICATIONS

Please list any current licenses or certifications that you hold, including driver’s license, CPR, First Aid, lifeguarding certifications, etc. and include a copy with this application.

______

Driver’s License Number State Renewal Date

REFERENCES

Please list 2 professional references (not family nor friends) and 1 personal reference (family, friend, mentor, coach, etc.).

Interests/ Match Preferences

Check all that apply!

1.  General

2.  playing sports

3.  cultural events

4.  music

5.  outdoor activities

6.  Other

Please list any other interests or hobbies of yours that you believe we should consider in our matching process.

What are the most convenient times for you to meet with your mentee? Please check all that apply.

____ Weekdays ____ Lunchtime ____ After school ____ Evenings ____ Weekends ____ Other

How did you hear about Youth Leadership Mentoring? ______

Why do you want to be a mentor? What specifically excites you about YL Mentoring? Be specific please!

______

What qualities and skills do you possess that you feel would contribute the most to YL Mentoring? How do you feel these qualities and skills would impact our youth?

______

Our Youth Leaders come from a wide variety of economic backgrounds with a range of behavioral, social, and/or emotional needs. In what ways do you feel you are prepared to work with our youth?

______

On a scale of 1-10 (1 = very uncomfortable / 10 = very comfortable), how would you feel meeting your mentee or their family in an urban, inner-city neighborhood?
(Circle One)

1 2 3 4 5 6 7 8 9 10

On a scale of 1-10 (1 = very uncomfortable / 10 = very comfortable), how comfortable are you in working with minor social, behavioral, and/or emotional challenges (Such as, but not limited to Autism, ADHD, and foster children)?
(Circle One)

1 2 3 4 5 6 7 8 9 10

Do you have any special qualifications for working with minor social, behavioral, and/or emotional challenges (Such as, but not limited to Autism, ADHD, and foster children)?

______

INFORMATION RELEASE

I have applied for a volunteer position at Jameson, Inc. by completing this application form. I understand that employees of Jameson, Inc. may wish to contact my former employers, teachers, and references as indicated on the application to inquire about my past work record and characteristics as they relate to the position for which I am applying. I hereby allow Jameson, Inc. agents to make reference checks and background checks as pursuant to this application. I understand that the purpose of this inquiry will be to obtain information so that my qualifications will be reviewed, evaluated, and considered. In signing this waiver, I expressly authorize Jameson, Inc. agents to make these inquiries. This information will be kept confidential.

______

Signature Date

Please return this application to:

Jameson Camp

Attn: Program Manager-- YL,

2001 Bridgeport Road, Indianapolis, Indiana 46231

or Fax: 317-241-2762

or Email:

Letter of Recommendation

·  Please have the 2 professional references (not family nor friends) and 1 personal reference (family, friend, mentor, coach, etc.) listed above fill out and return the Letter of Recommendation on the following page.

Applicant’s Name: ______

Position(s) for which this person is applying: ______

This individual has applied to be a mentor with Jameson Camp’s YL Mentoring, a one-on-one, community-based youth mentoring program. We would greatly appreciate your honest and candid evaluation of this individual. This information will be held in the strictest of confidence. Processing of the candidates’ application will not continue without Jameson Camp receiving this reference.

All YL Mentors will work with 13 - 18 year olds from diverse backgrounds with a variety of social, emotional, and/or behavioral needs. They must be excellent role models whom parents would want their children to emulate.

If you have any questions, please feel free to call 317-241-2661. We thank you for your assistance in helping us choose the best role models for our youth.

1.  Please indicate your relationship to the candidate: ______

2.  How long have you known the candidate: ______

3.  YL Mentoring serves many low-income, single-parent families, many of whom have a variety of challenges that they face. Do you think that this person is flexible enough to work with families whose lifestyles may challenging, irregular, or even very different from his/her own? Please explain.

4.  Dependability is one the most important traits of a successful mentor. A mentor must be able to keep appointments, make a 2-year commitment to a youth (ages 13-18), and be mature enough to cope with a youth’s special needs. Do you feel that this person is capable of making such a commitment to a youth? Please explain.

5.  Please comment on other characteristics that you feel qualify this person to become a mentor.

6.  Do you have any reservations about recommending this person for YL Mentoring? If so, please explain.

7.  Please indicate how strongly you would recommend this person:

Very Strongly Strongly Noncommittally Do not recommend

Please check the box that best applies to the applicant:

Would you personally be happy to have your own child under this person’s direct care and influence?

Please explain your answer: ______

______

Name of reference: ______Company: ______

Position: ______Signature: ______

Address: ______City/State/Zip:______

Phone: (_____) ______Date: ______

Please return this form to:

Jameson Camp

Attn: Program Manager-- YL,

2001 Bridgeport Road, Indianapolis, Indiana 46231

or Fax: 317-241-2762

or Email: