Mentor Application - MS Youth Challenge
STATE OF MISSISSIPPI MISSISSIPPI NATIONAL GUARD YOUTH CHALLENGE ACADEMY Building 80, West Jackson Ave CAMP SHELBY. MISSISSIPPI 39407-5500 Dear Potential Mentor, Thank you for your interest in becoming a Mentor for one of our applicants. A Mentor is simply someone who will be a friend and help guide the Cadet while he is here and after he returns home. In many instances, the Mentor serves as a bridge between success and failure in the youth’s life. Mentor Requirements are: Complete entire Mentor Packet before selection of class Must be same gender as applicant Must be a responsible mature adult (at least 21 years of age) Not a relative (i.e., parent/step-parent, grandparent/step-grandparent or sibling/step-sibling, or inlaws) regardless of where they live No-one living in the same household as the applicant Should live within commuting distance from applicant Someone willing to make a 17 month commitment to applicant through 22 weeks at Camp Shelby and 12 months after graduation Must attend a MANDATORY one-day “Mentor Training Day” on an assigned Saturday at Camp Shelby. Mentor Packet includes: 2 page Application Mentor Job Description 2 – Mentor Personal References to be completed by two different individuals. Questionnaire Authorization for background check performed by Petal Police Department Upon receipt of the application, this office will furnish you with a typed request authorizing a Department of Human Services Common Central Registry Application. You must sign and return this form immediately. The administration and staff of the MS Youth ChalleNGe Academy thank you for your assistance, and we look forward to communicating with you in the future. If you have any questions, contact Mrs. Toni Travis at 601-558-2239, [email protected]. Fax number is 601-558-2109. Sincerely, William H King IV Lieutenant Colonel, LG, Mississippi Army National Guard Director, Mississippi Youth ChalleNGe Academy Enclosures MS Youth ChalleNGe Academy Building 80, West Jackson Avenue ATTN: RPM Department Camp Shelby, MS 39407-5500 MENTOR APPLICATION – (to be completed in INK) First Name: __________________Middle Name: ________________ Last Name: ___________________ Suffix: _____ Application Date: _____________ Have you previously been a YCA Mentor? Yes No Name of Applicant who you will mentor: ____________________________________________________ Relationship to Applicant: _____________________ How long have you known Applicant?___________ Gender: Male Female Ethnicity: _______________ Marital Status:_______________________ Date of Birth: _________________ SSN: _____________________Drivers License #: _______________ Occupation: __________________ Employer: __________________________Work Status:___________ Home Phone: _________________________ Work Phone: ______________________, ext. ___________ Fax Number: __________________ Cell Phone: ___________________________________ Other Phone: ____________________ Other Phone Description __________________________________ Email Address: _________________________________________________________________________ Mailing Address: ______________________________________________________________________________________ Physical Address (if different): ______________________________________________________________________________________ City: __________________________ State: ____ Zip: ________________ County: __________________ 1. Why do you wish to become a Mentor with the Youth ChalleNGe Academy (YCA) (be specific)? ______________________________________________________________________________________ ______________________________________________________________________________________ 2. Health: Poor Fair Good Excellent Any physical limitations or special concerns? _____________________________________ ______________________________________________________________________________________ 3. Explain any use of alcohol or any other drugs, to include dates. ______________________________________________________________________________________ ______________________________________________________________________________________ 4. Do you have a valid driver’s license? Yes No 5. Have you ever been convicted of a crime? Yes No If yes, please explain (include dates) ___________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 6. Do you own a computer? Yes No 7. Do you have Internet accessibility? Yes No This information is true and accurate to the best of my knowledge. MENTOR/CADET LIABILITY STATEMENT I understand and agree that I will be the one actually spending time with my Cadet, and that I must exercise care in supervising while we are together. I agree that the Youth ChalleNGe Academy will not be liable for, and I agree to hold the Youth ChalleNGe Academy harmless from any and all liability, causes of action and losses imposed on it in any way relating to or arising out of this mentoring agreement, including, but not limited to, liability for personal injuries, whether the liability, cause of action, or loss is caused by my negligence, or Youth ChalleNGe Academy, its officers, agents, servants, employees, or otherwise. I do consent to being photographed and/or videotaped while attending Mentor Day at Camp Shelby and to have such photographs and/or videos posted on the official Mississippi Challenge Academy website, for official, non-commercial purposes only or in brochures for advertising purposes only. Mentor’s Printed Name ____________________________________ Mentor’s Signature _____________________________ Date ________________________ This application version supersedes all previous versions. Please destroy earlier versions. Local reproduction authorized. Revised January 2013 MENTOR JOB DESCRIPTION DUTIES and RESPONSIBILITIES The Mentor: Engages, in good faith, to a 17-month commitment with the Mentee. This includes the 22 weeks they are at Camp Shelby and 12 Months at home, after graduation. After graduation, four contacts per month is the standard requirement of which at least two must be face to face. Other contacts can be by phone, mail, email, or text. Submit monthly reports to Post-Residential Staff. Promptly returns all screening material as required. Attend a one-day (Saturday) Mentor training session, at Camp Shelby, better known as “Mentor Day.” This is a graduation requirement for the Mentee. Assist the Mentee with the Post-Residential Action Plan (P-RAP) development and discusses his/her progress. Mentors should observe all program policies and guidelines. Discuss possible violation of policies and/or issues with the Case Manager or Mentor Department. Refers the Mentee to other community resources when appropriate, and helps the Mentee access those resources. Mentor Signature: _______________________________________ Date: ________________ Mentee’s Name:________________________________________________________________ Revised January 2012 Cadet’s Name:_____________________________________ POTENTIAL MENTOR PERSONAL REFERENCE (2 References Required) MENTOR OR APPLICANT SHOULD NOT COMPLETE THIS FORM. HAVE SOMEONE WHO HAS KNOWN THE MENTOR FOR AT LEAST 2 YEARS COMPLETE A REFERRAL FOR MENTOR. ____________________________________ has applied for volunteer work the MS National Guard Youth (Print name of Potential Mentor) ChalleNGe Academy, which focuses on the needs of young adults. This Potential Mentor is being considered for a position with one of our applicants. We would like your help in learning more about this person. Please answer all questions on this form to the best of your knowledge and opinion. All information received will be confidential. How long have you know the Potential Mentor? __________ In what way?________________ Does the Potential Mentor have a good home relationship? ______________________________ Does the Potential Mentor work well with others? _____________________________________ How would you rate the Potential Mentor concerning: Personal Habits Excellent Good Average Poor Character Excellent Good Average Poor Morals Excellent Good Average Poor Compassion for others Excellent Good Average Poor Completes Commitments Excellent Good Average Poor Emotionally Stable Excellent Good Average Poor Receives Constructive Criticism Excellent Good Average Poor Health Excellent Good Average Poor Additional Comments: _______________________________________________________________________________________ _______________________________________________________________________________________ Print Name of person giving reference: ______________________________ Cell Phone: _______________ Home Phone: ___________________ Email Address:____________________________________________ Signature of person giving reference: ________________________________ Date: _________________ This application version supersedes all previous versions. Please destroy earlier versions. Local reproduction authorized. Revised April 2014 Cadet’s Name:_____________________________________ POTENTIAL MENTOR PERSONAL REFERENCE (2 References Required) MENTOR OR APPLICANT SHOULD NOT COMPLETE THIS FORM. HAVE SOMEONE WHO HAS KNOWN THE MENTOR FOR AT LEAST 2 YEARS COMPLETE A REFERRAL FOR MENTOR. ____________________________________ has applied for volunteer work the MS National Guard Youth (Print name of Potential Mentor) ChalleNGe Academy, which focuses on the needs of young adults. This Potential Mentor is being considered for a position with one of our applicants. We would like your help in learning more about this person. Please answer all questions on this form to the best of your knowledge and opinion. All information received will be confidential. How long have you know the Potential Mentor? __________ In what way?________________ Does the Potential Mentor have a good home relationship? ______________________________ Does the Potential Mentor work well with others? _____________________________________ How would you rate the Potential Mentor concerning: Personal Habits Excellent Good Average Poor Character Excellent Good Average Poor Morals Excellent Good Average Poor Compassion for others Excellent Good Average Poor Completes Commitments Excellent Good Average Poor Emotionally Stable Excellent Good Average Poor Receives Constructive Criticism Excellent Good Average Poor Health Excellent Good Average Poor Additional Comments: _______________________________________________________________________________________ _______________________________________________________________________________________ Print Name of person giving reference: ______________________________ Cell Phone: _______________ Home Phone: ___________________ Email Address:____________________________________________ Signature of person giving reference: ________________________________ Date: _________________ This application version supersedes all previous versions. Please destroy earlier versions. Local reproduction authorized. Revised April 2014 Questionnaire for Potential Mentor Today’s Date: __________________ Applicant’s Name: ______________________________________________________________ Potential Mentor’s Name: ________________________________________________________ 1. As the potential mentor, what are your plans for keeping this applicant on a positive path? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 2. What are your expectations in this relationship? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 3. On a scale of 1 to 10, with 10 being great self control, how would you rate yourself on your ability to deal with stress? _______ How would your peers rate you? _______ 4. Are there any plans of relocating outside of Mississippi within the next 12 months?_______ If so, for what reason are you relocating? ________________________________________ 5. What is your prior work experience with young adults? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________ 6. Should the program need to contact you for any reason, when would you prefer to be called and what is the best number to reach you. _________________________________________ 7. Will you be able to attend the “MANDATORY” Mentor Training Day, at Camp Shelby, on an assigned Saturday? ○ YES ○ No 8. Are there any questions or comments you would like to express? ___________________________________________________________________________ This application version supersedes all previous versions. Please destroy earlier versions. Local reproduction authorized. Revised January 2012 City of Petal P P DEPARTMENT OF POLICE 127 W 8th Avenue Petal, MS 39465 601-544-5331 D 601-544-5347 {Fax} __________________________________________________________________ I, _______________________________________ hereby authorize the (Potential Mentor Name: Print) Petal Police Department to check all of the department’s records, for use as a criminal history background check. I also authorize the following person, business or organization to receive a copy of this background check. MS Youth Challenge Academy Building 80, West Jackson Avenue ATTN: RPM Department Camp Shelby, MS 39407-5500 601-558-2621 _______________________________ SIGNATURE _______________________________ DATE City of Petal P DEPARTMENT OF POLICE 127 W 8th Avenue P Petal, MS 39465 601-544-5331 D 601-544-5347 {Fax} __________________________________________________________________ Criminal History Background Check Name (printed): ____________________________________________________ Date of Birth: ______________________________________________________ Driver’s License Number: ____________________________________________ State Issued: _______________________________________________________ ___________ Criminal History Found ___________ No Criminal History Found Signature and title of official conducting background check: __________________________________________________________________ Date of Background Check _______________________
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