Central Montana Youth Mentor Application

CMYM: PO Box 532 Lewistown MT 59457 [email protected], 535-8899

Application due: September 21

Date: _________________ Returning Mentor? ______Y______N Years you mentored: _____________________________ Last name: ____________________________________ First name: ________________________ Middle Initial: ____________ Address: _______________________________________________________________________________________________ Nickname: _____________________________ Age: ________ Grade level: ___________________ Gender: _____M_____F Cell phone: ________________ Home phone: ________________ email: __________________________________________ Parent Information: Name: _______________________________________________________Relationship to mentor: ____________________________ Hm. phone: ___________________ Cell: _______________________Employer: _________________________ Wk.phone: __________________ Address: _________________________________________________________best way to contact: ___ email ___home ___cell ___ work ____text Legal Guardian? ____Y ____N Email: ____________________________________________________ Willing to help with CMYMP events? ___Y ___N

Name: _______________________________________________________Relationship to mentor: ____________________________ Hm. phone: ___________________ Cell: _______________________Employer: _______________________ Wk.phone: ____________________ Email: _________________________________________________ best way to contact: ___ email ___home ___cell ___ work ____text Legal Guardian? ____Y ____N Other contact person: ____________________________________________________________________ phone: _________________________

All questions must be answered to be considered for the program. 1.) Why are you interested in being a mentor?

2.) Briefly describe a person who has been a mentor to you, the qualities he/she has and why they are important to you.

3.) Why are you a positive role model for a younger person?

4.) List the extracurricular activities you will be involved with this year. How will you plan to mentor as well as participate in other activities?

5.) Have you ever been cited for a traffic violation or convicted of a crime? _____Y _____ N If yes, please explain:

6.) Do you give permission to CMYMP to publish your photo in the New Argus, newsletter or other promotional materials? If under age 18, please have parents initial: Yes: ___________________ No: _______________________

Matching Preferences: If you are a returning mentor: do you wish to have the same mentee as last year? ____Y ____N If so, list the mentee’s name: ________________________________________________________________________ Grade level of mentee you wish to mentor: Gr. 1-3 ________ / Gr. 4-6 _________ / no preference __________ Matches are made by gender; boy mentors with boy mentees and girl mentors with girl mentees. However, female mentors are sometimes matched with boy mentees. Is this a problem for you? ____Y ____N why?

List the days that you are not available to meet with your mentee.

Describe your experience with young children, their ages and relationship to you.

Mentor requirements and agreements: The agreement is required for 7 consecutive months, October through April. Failure to follow through on commitments can result in dismissal from program. Read and initial the following agreements: As a mentor you agree to: Read handbook and all materials from advisors.____________ Attend monthly events _____________________ Attend pre-service training and interview ____________ Meet with mentee once a week _________________ Attend mid-year training __________________ Meet in approved places ___________________ Report hours to advisor __________________ Call mentee parents when plans are made or changed ___________ I understand I can be dismissed from the program if I do not fulfill my commitments. _____________________________ Parent signature: ________________________________________________________ Date: ____________________ Parent Permission for mentor operation for private vehicle to transport mentee. Please complete only if you intend to drive with your mentee in the vehicle. I give permission for my child ___________________________to drive his/her mentee for the current school year to mentor program activities. Parent / guardian signature: ___________________________________________ Date: _________________ I agree to only drive an insured vehicle with my mentee in the rear seat, properly buckled in and only to activities related to my job as a mentor representing CMYMP. I understand and agree that I am to drive only my mentee and will not drive friends or the mentee’s friends when I am with my mentee. Mentor signature: ____________________________________________________ Date: _________________ Parent / guardian signature: ___________________________________________ Date: _________________ THIS FORM IS NOT COMPLETE UNTIL YOU TURN IT INTO YOUR SCHOOL ADVISOR WITH A COPY OF YOUR DRIVER’S LICENSE AND INSURANCE CARD. ONLY THEN CAN YOU BEGIN TO DRIVE WITH YOUR MENTEE IN THE VEHICLE.