Prevention Mentor Program 2017

New Preventionist Application

Contact Information

Preventionist
Organization
Address
Work Phone & Email

Availability & Interest

What level of support and interaction do you hope to have with your mentor?

☐ High (2-3 times/month) ☐ Moderate (once a month) ☐Low (every other month)

In this program, I would like to engage with my match by:

☐ Phone calls ☐ Exchanging emails ☐Have my mentor visit my program

☐Visit my mentor’s program ☐Shadow my mentor during prevention programs

Prevention Experience

How long have you been doing SV Prevention?

☐ In the first year ☐ 1 year- 2 years

Even though you may still be just figuring this out, can you briefly share your philosophy in prevention?

Use this space if you have other professional expertise that you think would help in matching you with a mentor.

Audience/CommunityExperience

I anticipate working with/ want to increase my capacity to workthe following populations, communities and/or settings (check as many as apply):

☐ Young Kids/Elementary ☐ Middle School Youth ☐High School Youth

☐ College/Young Adults ☐ Adults ☐Caregivers/Parents

☐ Rural Communities ☐ Island Communities ☐Urban Environments

☐ Classroom Programs ☐ School Clubs ☐Community-Based Programs

☐ Alternative Schools ☐ Faith Communities ☐Athletic Programs

☐ Native American ☐ Latin@ ☐Immigrant/Refugee

☐ Asian Pacific Islander ☐ Deaf/Blind ☐African American

☐ LGBTQ ☐ Intellectual/Dev Disability ☐Other, please describe below

Use this area if specific populations/areas of expertise are not captured above or if there is more detail that would aid in our matching process.

Subject Matter Experience

I am most interested in building capacity to teach/utilize the following concepts/ approaches (check as many as apply):

☐ Healthy Sexuality/ Sexual Health ☐ Teen Dating Violence / Healthy Relationships

☐ Youth Bystander Programs ☐ Adult/College Bystander Programs

☐ Child Sexual Abuse Programs ☐ Media Literacy

☐ Anti-Oppression ☐ Coaching or Athletics Programs

☐ Engaging Men/Boys ☐ Harassment/ Bullying

☐ Youth/ Peer Leadership ☐ Community Development/ Organizing

Use this area if specific areas are not captured above or if there is more detail that would aid in our matching process.

Mentorship

Please describeany goals or what you hope to gain from this program:

What type of support with SV Prevention is available to you outside of this program?

☐My agency sends me to in-person trainings ☐ Mostly rely on free, online training

☐Other staff in my org with prevention experience ☐Community coalitions/ partners

☐I’m not sure ☐Other -- use space below

Agreement

By submitting this application, I am agreeing to the terms of the program and that my organization supports my participation in this program.

Name / Date

Submission

Please save this application with your last name in the file name and email to by July 31, 2017.

* On-going applications will be accepted and some awards may be given on a rolling basis depending on financial availability.

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