Please enable JavaScript in your browser to complete this form.Mentor application formDate Personal informationName *FirstLastAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email * Date of birth *Shirt size *Choose oneChoose oneSmallMedium LargeX Large2X Large3X LargeMentor ProfileOccupation *Motivation and Commitment *What motivates you to become a mentor, and how do you plan to remain committed to supporting your mentee throughout the Champion Circle program?Experience and Qualifications *Can you share your previous experiences working with youth or in mentorship roles? What skills or expertise do you bring that would benefit the participants?Approach to Mentorship *How do you build trust and rapport with young individuals? What strategies do you use to address challenges or conflicts that may arise during the mentoring relationship?Understanding of Youth Empowerment *What does youth empowerment mean to you, and how do you stay informed about the issues and challenges facing today's youth?Program Alignment *How do you see your role contributing to the goals of this specific program? What are your expectations from the program organizers to support your mentoring efforts?Mentor AssessmentHave you been convicted of any crimes in the last 10 years, including offenses against persons or families, public indecency, or controlled substance violations? *YesNoIf the answer is YES, please explain below:Educational background. (check all that apply): *Some high schoolGEDHigh school graduateSome collegeCollege graduateGraduate/professional schoolTechnical schoolOtherOtherPlease indicate the days of the week you are available to mentor. We are seeking mentors who can offer regular availability to effectively support our youth participants. (Check all that apply):MondayTuesdayWednesdayThursdayFridaySaturdaySundayPlease indicate the most convenient times for you to mentor. (Check all that apply):MorningsAfternoonsEveningsWeekdaysWeekendsPersonal referencesPlease list two references (you may include family members, personal friend and/or work reference):Reference One *FirstLastPhone numberReference Two *FirstLastPhone number DISCLAIMER AND ACKNOWLEDGEMENTBy submitting this application, you acknowledge and agree to the following: Program Participation: Participation in the Champion Circle program is a privilege and is subject to availability. Acceptance into the program is contingent upon the completion of all necessary paperwork, including consent and background checks (if applicable). Mentor Responsibilities: As a mentor, you understand that your role includes providing guidance, support, and encouragement to a youth participant. You agree to be a positive influence and dedicate the necessary time to assist your mentee in achieving their personal and academic goals. Confidentiality: You understand and agree that any personal information shared by your mentee is confidential and will not be disclosed to others without prior consent, unless required by law. Liability Waiver: You acknowledge that by participating in the Champion Circle program, you do so at your own risk. The Give A Day Foundation and its partners are not liable for any injury or harm that may occur during your participation in program activities. Photo and Media Release: You grant permission to the Give A Day Foundation to take photographs or videos during the program that may include your image or voice. These materials may be used for promotional purposes, including but not limited to social media, websites, and marketing materials, unless you request otherwise in writing. Commitment: By applying to be a mentor, you commit to attending all required meetings, training sessions, and mentor-mentee activities as outlined by the program. You also agree to maintain communication with the program coordinator throughout your participation. Termination: The Give A Day Foundation reserves the right to terminate your involvement in the Champion Circle program at any time if you fail to meet the program's expectations or if there is a violation of the code of conduct. By submitting this application, you acknowledge that you have read and understood the terms and conditions outlined in this disclaimer and agree to abide by them.SignatureClear SignatureSubmit
