Member Agency Information

Contact Information

Date:

Agency Name:

Address:

City: Zip:

Phone: Fax:

Website: E-mail:

Executive Director:

Contact Person (name and title):

Program Description

Please describe your program in terms of its mission, goals, etc.

Please return completed forms to;
Gary Graham
Senior Outreach Coordinator, Mentor Center of Palm Beach County
c/o Children’s Services Council
2300 High Ridge Road
Boynton Beach, Florida33426
or
(561) 740-7000 FAX (561) 835-1956

Program Description, continued

Programs offered: (check all that apply)

One to One Mentoring
(one volunteer and one mentee) / Group Mentoring
(one or more volunteers with a group of participants)
During School Hours
At school
At the workplace / During School Hours
At school
At the workplace
After School Hours
At school
At church or temple
At aterschool program
At community center
Other:______/ After School Hours
At school
At church or temple
At afterschool program
At community center
Other:______
Weekends
Where?______/ Weekends
Where? ______

What age group does your agency serve (check all that apply)?

Under 5 years old / K-5th grade (5-10 years old)
6-8th grade (11-13 years old) / 9-12th grade (14-18 years old)
18+ years (specify)

How many children or young families are currently receiving mentoring services?

How many children or young families are currently on a waiting list for mentors?

How are children/young families referred to your mentoring program?

School system (counselors, teachers,etc.) / Self or family
Department of Juvenile Justice / Other

Please describe the criteria for children or young families to be eligible for mentoring services in your program(s). (i.e. age, geographic location, socio-economic status, etc.)

Is your organization associated with or in collaborative partnerships with any other agencies at this time? If yes, please list:

Program Description, continued

What areas of Palm BeachCounty does your mentoring program serve?

North County: Jupiter-Tequesta, Juno, North Palm, Lake Park, Riviera Beach, P.B. Gardens

CentralCounty: West Palm, MangoniaPark, Greenacres, Lantana, Lake Worth

SouthCounty: Boynton Beach, Delray Beach, Boca Raton

WestCounty: Royal Palm Beach, Acreage, Wellington, Belle Glade, Pahokee, SouthBay

Other areas:

Volunteer Information

Volunteers are utilized in your agency in what capacity?

As mentors / As guest speakers(topics?)______
As coaches / As tutors
As agency support (clerical,
fundraising,etc.) / Other

Volunteer mentors in your agency are:

Adults- age 18+
High school students / Seniors –age 65+
College students

What is the minimum age requirement for mentors?

What is the time commitment a mentor must make to a child/family in your program? (i.e. 2 hours per week for at least one year) Please specify if your program has more than one mentoring component or time requirement:

What specific time/day(s) are mentors needed to serve?

School/work days (Monday-Friday) / Weekends
School/work times (8a.m.-3or4p.m.) / After 3p.m.
Flexible

Is your organization or agency able to provide verification of volunteer liability insurance and/or a written plan regarding volunteer risk management issues?

Volunteer Screening Information

Please provide the following information as it pertains to volunteer mentors in your organization.

Does your organization utilize any of the following tools in the mentor screening process? (Check all that apply currently):

FDLE Police Record Check / Personal and/or Employer References
Fingerprinting by agency staff
Fingerprinting through Sheriff’s Office
In-person Interview
Home Visit Interview / (If so, how many) ______
Safety Net
PBCSchool District Background Screen

What other screening elements are used?

What type of supervision do volunteer mentors receive in your organization?

In-person contact with staff / Telephone contact with staff
On-site continuous / Other(describe):
Email contact

How often do volunteers receive supervision or monitoring?

Weekly / Monthly
Continuously (each time they see a child)
Other(describe) / Every two weeks

Do volunteer mentors receive orientation and/or ongoing training during their commitment? Please describe the required or offered training and how long each training is.

Other Program Information

How many volunteers are currently active in your program?

How many volunteers are needed as mentors at this time?

Is your organization able to utilize seasonal residents as mentors?

In other volunteer capacities? How?

Please include any further information that you believe may help the MentorCenter to understand your agency or program better.

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memberagencyinfo.doc.