Mentor Application

Mentor Application

The Woman to Woman Mentoring Program is committed to ensuring diversity in its program. Questions about age help qualify candidates within the age groups specified by the service requirements. Questions about past experiences, educational pursuits, professional interests, hobbies, etc. provide information to help ensure the mentoring program engages a variety of knowledge, backgrounds, experience and attitudes that encourage, enable and sustain growth and learning.

First Name:*

Last Name:*

Street Address:*

City:*

State:*

Zip Code:*

Preferred Phone:*

Alternate Phone:*

Email Address:*

Date of Birth:*

Age*

Do you work in Frederick County? If yes, where? If no, please contact us for more info. We currently serve the Frederick County region.*

Are you on Facebook?*
YesNo


Please answer the following questions as completely as possible.


How did you learn about Woman to Woman Mentoring Inc.?*

Why do you want to become a mentor?*

What do you hope to get out of the mentoring experience?*

Do you have any previous experience volunteering or mentoring? If so, please describe.*

What industry or field is your specialty?*

What qualities, skills, or other attributes do you feel you have that would benefit a young woman in formulating and achieving her goals with regard to education, career, and family?*

What are your hobbies and how do you like to spend your leisure time?*


The Woman to Woman Mentoring program requires commitment and perseverance along with a healthy dose of reality. Are you willing to accept the following program requirements? Please check each requirement as you agree to it.


I am willing and able to:*
Actively participate for a minimum of ten months from the time I am matched with a mentee
Attend a Meet and Greet workshop
Attend an initial mentor orientation session
Attend monthly evening workshops (usually on Tuesday or Wednesday nights from 6-9 p.m.)
Meet with my mentee a minimum of two-four hours per month
Maintain contact with my mentee in person or by phone at least once a week
Submit monthly email/written reports to program staff regarding our mentoring activities & progress
Communicate regularly and openly with program staff
Participate in program assessments
Receive and objectively consider feedback regarding any difficulties during my participation in the mentoring program


Please explain any particular issues that would challenge your ability to keep the above commitments.*

How would you describe yourself using 2-3 words?*

Have you ever been arrested or convicted of a crime? If so, what were the circumstances?*

Have you ever received treatment for alcohol or substance abuse? If yes, please explain.*

Have you ever been treated or hospitalized with a mental illness? If yes, please explain.*


Educational History


Please list the schools you have attended and the degrees/certifications you have completed.*


Please list any other cities, states, and dates of residency during the past 10 years.


City:

State:

From m/year to m/year:

City:

State:

From m/year to m/year:

City:

State:

From m/year to m/year:


Personal References


Reference 1


Name:

Street Address:

City:

State:

Zip Code:

Email:

Phone:

Relationship:

How long known:


Reference 2


Name:

Street Address:

City:

State:

Zip Code:

Email:

Phone:

Relationship:

How long known:


Reference 3

Name:

Street Address:

City:

State:

Zip Code:

Email:

Phone:

Relationship:

How long known:


Employment History
Please provide employment information from the past 5 years starting with your current position.


Current Employment


Employer:

Job Title:

Street Address:

City:

State:

Zip Code:

Supervisor's Name:

Phone Number:

Dates of employment:

Primary Responsibilities:


Employer 2


Employer:

Job Title:

Street Address:

City:

State:

Zip Code:

Supervisor's Name:

Phone Number:

Dates of employment:

Primary Responsibilities:


Employer 3


Employer:

Job Title:

Street Address:

City:

State:

Zip Code:

Supervisor's Name:

Phone Number:

Dates of employment:

Primary Responsibilities:


Mentor Application Agreements and Information Release


Please read this carefully before signing:

I understand that information about me will be anonymously (without my name) shared with a prospective mentee to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and any other information about me may be shared with the mentee to ensure and aid in facilitating a safe and successful match relationship.

I attest that I have no driving record convictions such as Driving Under the Influence (DUI), reckless driving, or excessive speed violations.

I agree to hold harmless Woman to Woman Mentoring Inc. and Frederick Community College (from whom W2WM leases office space and classroom space), its officers, agents, and employees from and against all claims, damages and losses, including reasonable attorney’s fees, court costs, and other expenses arising out of or resulting from any acts, errors or omissions of the mentee I am assigned in the performance of the services set forth in the Agreement.

I pledge to abide by all the rules and policies regarding Woman to Woman Mentoring Inc.

I certify that the information contained on this Authorization Form is true and correct and that my application may be terminated based on any false, omitted or fraudulent information.

By signing below, I attest to the truthfulness of all information listed on this application, I authorize Woman to Woman Mentoring, Inc. to verify the information and I agree to all the above terms and conditions.

Signature:*

Date:*

**Please bring your picture ID to your interview.

Woman to Woman Mentoring Inc. is committed to ensuring diversity in its program. Questions about age help qualify candidates within the age groups specified by the service requirements. Questions about past experiences, educational pursuits, professional interests, hobbies, etc. provide information to help ensure the mentoring program engages a variety of knowledge, backgrounds, experience and attitudes that encourage, enable and sustain growth and learning.

Woman to Woman Mentoring Inc. appreciates your interest in becoming a mentor.

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