Mentor Application Mentor Application Thank You for your interest in volunteering as a BCYMP Mentor. After you complete this form, the BCYMP Mentoring Coordinator will email you the training steps you'll need to take before being matched. We will also ask you to complete a form that gives BCYMP permission to run a background check. Finally, after you complete your training, we'll ask you to attend a brief interview to answer any questions you may have and to allow BCYMP to tell you more about the specific needs in our community. These steps help us make the best possible Mentoring Match. Also, we ALWAYS need more Mentors, so please share this opportunity and application with any caring, responsible adult you know who'd be willing to spend one hour a week with student(s) in need of guidance and support. To the world you may just be one person, but to one person, you may be the world. #BCYMPBeOne About You Name * Date of Birth * Gender * Preferred Pronouns (ex. she/her/hers) Ethnicity * Local Address * Local Address Local Address Local Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Employer Are there any special health care needs (physical, behavioral, emotional, dietary) we should be aware of? Additionally, please list any suggested accommodations we can make: Home Address (If you are an SDSU student, please put your home address, too.) Home Address (If you are an SDSU student, please put your home address, too.) Home Address (If you are an SDSU student, please put your home address, too.) Home Address (If you are an SDSU student, please put your home address, too.) City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Numbers Cell Phone * Carrier * Can we text you? Yes No Home Phone Work Phone Education Years of School * Enter location and years completed. Are you an SDSU student? * Yes No Enter your major and expected graduation date. * Please list any clubs, organizations, other community involvement you are connected to: * Background Do you have a valid drivers license? * Yes No Expiration Date * Has an employer or other organization run a Background Check on you in the last six months? Yes (If available, please email the results as a attachment to bcymp@bcymentoring.org) No Have you ever been convicted or arrested for a Felony Offense? If yes, explain. * Yes No Please explain, * Have you ever been investigated in connection with a child abuse. molestation or neglect matter? If yes, explain. * Yes No Please explain, * Mentoring Questions How did you hear about Brookings County Youth Mentoring Program (BCYMP)? * Why would you like to be a BCYMP mentor? * Please select which type(s) of mentoring you're interested in. (May select more than one option.) * 1:1 Mentoring *MOST NEEDED Small Group Mentoring/On-Site Mentoring (Set Schedule) 2:1 Mentoring (Couples/2 Friends with one Mentee) Mentor as a Family Unit with 1 Mentee (or siblings) If you would be interested in mentoring with an academic focus, please indicate which subjects and student age groups you're comfortable supporting. * Can you meet as often as our program requires? (4 hours/month for at least one year for 1:1 mentoring; if you're gone for the summer, BCYMP can accommodate your schedule.) BCYMP Mentors matched with small groups/on-site Mentees need to volunteer at least 1 semester or summertime. * Yes No Do you have any previous experience volunteering or working with youth? If yes, please list. * Yes No Please list. * Please list any of your hobbies/interests that would help us to better match you with a BCYMP Mentee. Anything you don't want to do/little interest in? * 19. What grade(s) do you prefer to mentor? (Check all that apply.) * Early Elementary Upper Elementary Middle School High School Do you have a gender preference for your Mentee? * Are you willing to support a Mentee that has unique social, learning, and/or physical needs? * Yes No Maybe Please describe any personal or educational experiences you have with people who have unique needs, and/or describe the kinds of individual needs you are comfortable supporting. * BCYMP serves all of Brookings County, it is often hard to find Mentors in the smaller communities. Please select which cities you are willing to have your Mentee from (select all that apply): Aurora Brookings Bruce Bushnell Elkton Sinai Volga White Preferred City to Mentor: Can you speak other languages? * Yes No Please list. * Reference 1 (not family) References: Please list the name, phone number, email, and connection for two personal references (not family) that you have known for at least one year Name * Email * Phone * Connection * Reference 2 (not family) References: Please list the name, phone number, email, and connection for two personal references (not family) that you have known for at least one year Name * Email * Phone * Connection * Did someone recommend you to the program? Yes No Name What else? Is there anything else you'd like to share about yourself and/or the kind of student you'd like to mentor? Any mentoring situation you would feel uncomfortable working with? Prior to being matched with a Mentee, BCYMP will need to run a background check, motor vehicle report, and ensure all BCYMP trainings are completed. Each mentoring pair costs BCYMP approximately $1000 each year. Will you consider a donation to offset your Mentor onboarding costs? Yes, I will donate $100. Yes, I will donate $75. Yes, I will donate $50. Yes, I will donate $25 Other AmountOther Amount No, I'm sorry, but can't make a donation at this time. Please connect with me to discuss more. For $20, we could order you a BCYMP Logo t-shirt. Would you like to purchase one? (Unfortunately, we don't have it in our budget to purchase t-shirts for all Mentors, but we have had the request for them, and don't want you to miss out if you want one!) Yes, size Small. Yes, size Medium. Yes, size Large. Yes, size XL. Yes, size 2XL. No thanks! I certify that all the information above is correct. * Clear By my signature below, I acknowledge that I am voluntarily assuming the risks involved in participating with/in Brookings County Youth Mentoring Program (BCYMP). * Clear By my signature below, on behalf of myself, my heirs, next of kin, successors in interest, assigns, personal representatives, and agents, I hearby (1) waive any claim or cause of action against and release from liability the Brookings County Youth Mentoring Program (BCYMP), its officers, employees, Mentors, and agents for any liability for injuries to my person or property resulting from my participation in/with BCYMP. (2) Agree to indemnify and hold harmless the Brookings County Youth Mentoring Program (BCYMP), its officers, employees, Mentors, and agents fro any claims, causes of action, or liability to any other person arising from my participation with BCYMP; and (3) consent that I am personally liable for any, or all, lost or damaged personal items/equipment. * Clear Email Date If you are human, leave this field blank. Submit
