VOLUNTEER ONLINE

NAME * DATE *
As a mentor in the Take Stock in Children program, I will always act in a manner that is in the best interest of my student.
I will notify Take Stock in Children if I must terminate my mentor position for any reason.
I will notify my student or his or her school liaison or the Take Stock in Children Student Advocate if I am unable to attend a previously scheduled meeting.
I will not willfully arrange contact with my student off school property and not under the supervision of Take Stock in Children or the local program.
I will not drive my student in my car.
I understand that Take Stock in Children will terminate my relationship with my student if I violate any of the above policies.

Please complete the following information
Home Phone:*
Cell Phone:
Home Address:
E-mail:
Employer (Company Name):
Job Title:
Work Address:
Work E-mail:
Work Phone:
Fax:
Preferred Method of Contact for Program Information:
 Email US Mail

Demographic Information

Social Security Number:
Language:
DOB:
Bilingual: Yes
Driver License:
Ethnicity:
Gender:

Race B/W/H/O:


Educational Background

HSD
AS:
AA:

BS/BA:
MA:
PHD:


School Preference

School Choice:
School Name 1st Choice
School Name 2nd Choice

School Area:
Central     North East
North West     South


How did you learn about the Take Stock In Children?

TV/ Radio Ad
Newspaper/ Print Ad
Corporate Presentation

Mailing
Word of Mouth: (Please specify so we may thank them)
Other Specify


REFERENCES


If you are currently employed, please print the name and address of your work supervisor:

Name:
Complete address:

Phone:


Please list two references: (Include one work reference and one family member or a personal friend.)

WORK

Name:
PERSONAL

Name:
Address:
Address:
City:
City: :
State:
State:
Zip:
Zip:
Home#:
Home#:
Cell#:
Cell#:
Work#:

Work#:


Please complete the following in-depth interest form to help us know you better and match you with the correct student.

1. How would you describe your communication style?

Life of the party
Friendly and outgoing
Usually wait to be approached by someone new
Reserved until I get to know the person
None of the above (please describe):


2. What type of student would you prefer to mentor?

Aggressive, the one who takes the lead
Very involved and open
Participatory but not too assertive
Reserved and on the quiet side
Any style is fine with me
Other (please describe):


3. I am interested in becoming a mentor with Take Stock in Children because (check all that apply)

I think I’d be a positive role model
I like children
I have the time to give
I overcame difficulties growing up and would like to help someone else
I think I have the personality and abilities to be a good mentor
I am interested in a long term relationship with a child
I believe in the value of mentoring
I wish I had a mentor when I was in school


4. Please prioritize the following criteria you would prefer in a student:

Same ethnicity
Similar career interests
Similar personal interests
Similar backgrounds
Other (please specify):
No preference

5.How comfortable would you be in speaking with your student regarding his or her use of poor judgment?

Very comfortable
Somewhat
Not at all

6. How comfortable would you be in speaking with your student about drug or alcohol abuse?

Very comfortable
Somewhat
Not at all

7. Please indicate how comfortable you would be in talking to a student about the following:

  Very Comfortable Somewhat at all
a. World of work
b. Goal setting
c. Career planning
d. College planning
e. Personal experiences
f. Hobbies/interests
g. Personal problems
h. Drug awareness

 

8. What experience do you have in drug awareness education?



9. Please prioritize those activities that you see as most important in a mentor relationship?

Give advice on career options and decision making
Give advice on career options and decision making
Assist in job readiness activities
Participate in post-secondary education or training plans
Participate in school activities
Provide encouragement and support
Other


10. Please indicate how comfortable you would be in handling the following potential problems:
vc= very comfortable s=somewhat n-not comfortable

You have a hard time reaching your student
You make arrangements to meet and your student doesn’t show up
Your student seems unresponsive to your interest in getting to you him or her
Your student has little interest in your job/profession
Your student shares very sensitive information or thoughts with you

11. Are there any particular problems you would prefer not to handle as a mentor? (please explain)



12. How would you describe yourself as a teenager?

Troubled (at risk, serious problems and little success)
Typical (some problems and some success)
Above average (well adjusted and mostly successful)


13. As a teenager, did you have a mentor?

Yes
No
If yes, please describe your mentor:


14. List any clubs or organizations of which you are presently a member:



15. Background checks are required of every person seeking to become an in-school mentor. Would you have any objection to a background check before being accepted as a mentor?

Yes
No

16. Where would you prefer to mentor?

Closer to Home
Closer to Work

17. What time during the school day would you prefer to mentor?



18. What day of the week would you prefer to mentor?