community

School-Community Partnership Program

Stay in School Mentoring Project Application

How to Become a Mentor

Mentor Application 2012

Personal Information

First Name*	Last Name*
Male Female
Mailing Address	City
Zip Code
Home Phone	Cell Phone
E-mail Address*
Driver License Number

Educational Information

High School	GED
College	Major
Other

Employment Information

Position	Length of Employment
Supervisor's Name
Business Name	Business Address
Business City	Business Zip Code
Business Phone*	Business Fax

Previous Employment

Previous Employer	Employer Address
Position	Dates Employed

Previous Employer	Employer Address
Position	Dates Employed

Previous Employer	Employer Address
Position	Dates Employed

Volunteer Experience

Organization	Position
Years	Supervisor
Telephone

Organization	Position
Years	Supervisor
Telephone

Organization	Position
Years	Supervisor
Telephone
Other experiences with children?
Why do you wish to be a mentor?
Interests/Hobbies/Talents/Foreign Language Fluency

References

Name	Daytime Phone
Relationship

Name	Daytime Phone
Relationship

Name	Daytime Phone
Relationship

Name	Daytime Phone
Relationship

Additional Information

Where do you wish to be contacted? Work Home Other

Do we have your permission to contact your employer's Human Resource Dept. to verify information contained in this application? Yes No

Do you use illegal drugs? Yes No

Mentor Release Statement

I, the undersigned hereby state that if accepted as a mentor, I agree to abide by the rules and guidelines established by the Stay In School Mentoring Program and the Clark County School District. I understand that the program involves A. Application and reference/background checks; B. Background check; C. Interview Questionnaire; D. Training/orientation session; E. Commitment of one hour per week for one school year; F. Communication with school personnel or project coordinator, and G. Completion of an end of the year survey.
How did you hear about the Stay In Schools Mentoring Project?
I understand that the Stay In School Mentoring Program and the mentor/mentee relationship established must take place only within the confines of the school in areas designated by school personnel. Contact or activities outside of the school are not permitted at any time. The information supplied in this application may be verified, if necessary, by contacting individuals or organizations regarding information contained in this application. I hereby release and hold harmless from liability any person or organization which provides information. I also agree to hold harmless the Clark County School District, Partnership Office, employees and volunteers thereof. I certify that all information provided on this application is true and complete to the best of my knowledge. I understand that the mentoring program must protect and serve the safety and well-being of the students. As a result, the mentoring program reserves the right to refuse participation and/or terminate applicants/mentors at any time, at the discretion of the CCSD. I hereby grant CCSD permission to verify all information supplied in this application through contact with individuals, organizations, law enforcement agencies and child protective services.