Mentor Application - MS Youth Challenge

STATE OF MISSISSIPPI
MISSISSIPPI NATIONAL GUARD
YOUTH CHALLENGE ACADEMY
Building 80, West Jackson Ave
CAMP SHELBY. MISSISSIPPI 39407-5500
Dear Potential Mentor,
Thank you for your interest in becoming a Mentor for one of our applicants. A Mentor is simply someone
who will be a friend and help guide the Cadet while he is here and after he returns home. In many instances,
the Mentor serves as a bridge between success and failure in the youth’s life.
Mentor Requirements are:
 Complete entire Mentor Packet before selection of class
 Must be same gender as applicant
 Must be a responsible mature adult (at least 21 years of age)
 Not a relative (i.e., parent/step-parent, grandparent/step-grandparent or sibling/step-sibling, or inlaws) regardless of where they live
 No-one living in the same household as the applicant
 Should live within commuting distance from applicant
 Someone willing to make a 17 month commitment to applicant through 22 weeks at Camp Shelby
and 12 months after graduation
 Must attend a MANDATORY one-day “Mentor Training Day” on an assigned Saturday at Camp
Shelby.
Mentor Packet includes:
 2 page Application
 Mentor Job Description
 2 – Mentor Personal References to be completed by two different individuals.
 Questionnaire
 Authorization for background check performed by Petal Police Department
 Upon receipt of the application, this office will furnish you with a typed request authorizing a
Department of Human Services Common Central Registry Application. You must sign and return
this form immediately.
The administration and staff of the MS Youth ChalleNGe Academy thank you for your assistance, and we
look forward to communicating with you in the future. If you have any questions, contact Mrs. Toni Travis
at 601-558-2239, [email protected].
Fax number is 601-558-2109.
Sincerely,
William H King IV
Lieutenant Colonel, LG, Mississippi Army National Guard
Director, Mississippi Youth ChalleNGe Academy
Enclosures
MS Youth ChalleNGe Academy
Building 80, West Jackson Avenue
ATTN: RPM Department
Camp Shelby, MS 39407-5500
MENTOR APPLICATION – (to be completed in INK)
First Name: __________________Middle Name: ________________ Last Name: ___________________
Suffix: _____ Application Date: _____________ Have you previously been a YCA Mentor?  Yes  No
Name of Applicant who you will mentor: ____________________________________________________
Relationship to Applicant: _____________________ How long have you known Applicant?___________
Gender:  Male  Female
Ethnicity: _______________ Marital Status:_______________________
Date of Birth: _________________ SSN: _____________________Drivers License #: _______________
Occupation: __________________ Employer: __________________________Work Status:___________
Home Phone: _________________________ Work Phone: ______________________, ext. ___________
Fax Number: __________________ Cell Phone: ___________________________________
Other Phone: ____________________ Other Phone Description __________________________________
Email Address: _________________________________________________________________________
Mailing Address:
______________________________________________________________________________________
Physical Address (if different):
______________________________________________________________________________________
City: __________________________ State: ____ Zip: ________________ County: __________________
1. Why do you wish to become a Mentor with the Youth ChalleNGe Academy (YCA) (be specific)?
______________________________________________________________________________________
______________________________________________________________________________________
2. Health:  Poor
 Fair
 Good
 Excellent
Any physical limitations or special concerns? _____________________________________
______________________________________________________________________________________
3. Explain any use of alcohol or any other drugs, to include dates.
______________________________________________________________________________________
______________________________________________________________________________________
4. Do you have a valid driver’s license?
 Yes  No
5. Have you ever been convicted of a crime?  Yes  No
If yes, please explain (include dates) ___________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
6. Do you own a computer?  Yes
 No
7. Do you have Internet accessibility?  Yes  No
This information is true and accurate to the best of my knowledge.
MENTOR/CADET LIABILITY STATEMENT
I understand and agree that I will be the one actually spending time with my Cadet, and that I must exercise
care in supervising while we are together. I agree that the Youth ChalleNGe Academy will not be liable
for, and I agree to hold the Youth ChalleNGe Academy harmless from any and all liability, causes of
action and losses imposed on it in any way relating to or arising out of this mentoring agreement,
including, but not limited to, liability for personal injuries, whether the liability, cause of action, or loss is
caused by my negligence, or Youth ChalleNGe Academy, its officers, agents, servants, employees, or
otherwise.
I do consent to being photographed and/or videotaped while attending Mentor Day at Camp Shelby and to
have such photographs and/or videos posted on the official Mississippi Challenge Academy website, for official, non-commercial
purposes only or in brochures for advertising purposes only.
Mentor’s Printed Name ____________________________________
Mentor’s Signature _____________________________ Date ________________________
This application version supersedes all previous versions. Please destroy earlier versions. Local reproduction authorized.
Revised January 2013
MENTOR JOB DESCRIPTION
DUTIES and RESPONSIBILITIES
The Mentor:
Engages, in good faith, to a 17-month commitment with the Mentee. This includes the 22 weeks they are at
Camp Shelby and 12 Months at home, after graduation. After graduation, four contacts per month is the
standard requirement of which at least two must be face to face. Other contacts can be by phone, mail, email,
or text.
Submit monthly reports to Post-Residential Staff.
Promptly returns all screening material as required.
Attend a one-day (Saturday) Mentor training session, at Camp Shelby, better known as “Mentor Day.” This
is a graduation requirement for the Mentee.
Assist the Mentee with the Post-Residential Action Plan (P-RAP) development and discusses his/her
progress.
Mentors should observe all program policies and guidelines. Discuss possible violation of policies and/or
issues with the Case Manager or Mentor Department.
Refers the Mentee to other community resources when appropriate, and helps the Mentee access those
resources.
Mentor Signature: _______________________________________ Date: ________________
Mentee’s Name:________________________________________________________________
Revised January 2012
Cadet’s Name:_____________________________________
POTENTIAL MENTOR PERSONAL REFERENCE (2 References Required)
MENTOR OR APPLICANT SHOULD NOT COMPLETE THIS FORM. HAVE SOMEONE WHO HAS KNOWN THE
MENTOR FOR AT LEAST 2 YEARS COMPLETE A REFERRAL FOR MENTOR.
____________________________________ has applied for volunteer work the MS National Guard Youth
(Print name of Potential Mentor)
ChalleNGe Academy, which focuses on the needs of young adults. This Potential Mentor is being
considered for a position with one of our applicants. We would like your help in learning more about this
person. Please answer all questions on this form to the best of your knowledge and opinion. All information
received will be confidential.
How long have you know the Potential Mentor? __________ In what way?________________
Does the Potential Mentor have a good home relationship? ______________________________
Does the Potential Mentor work well with others? _____________________________________
How would you rate the Potential Mentor concerning:
Personal Habits
 Excellent
 Good
 Average
 Poor
Character
 Excellent
 Good
 Average
 Poor
Morals
 Excellent
 Good
 Average
 Poor
Compassion for others
 Excellent
 Good
 Average
 Poor
Completes Commitments
 Excellent
 Good
 Average
 Poor
Emotionally Stable
 Excellent
 Good
 Average
 Poor
Receives Constructive
Criticism
 Excellent
 Good
 Average
 Poor
Health
 Excellent
 Good
 Average
 Poor
Additional Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
Print Name of person giving reference: ______________________________ Cell Phone: _______________
Home Phone: ___________________ Email Address:____________________________________________
Signature of person giving reference: ________________________________
Date: _________________
This application version supersedes all previous versions. Please destroy earlier versions. Local reproduction authorized.
Revised April 2014
Cadet’s Name:_____________________________________
POTENTIAL MENTOR PERSONAL REFERENCE (2 References Required)
MENTOR OR APPLICANT SHOULD NOT COMPLETE THIS FORM. HAVE SOMEONE WHO HAS KNOWN THE
MENTOR FOR AT LEAST 2 YEARS COMPLETE A REFERRAL FOR MENTOR.
____________________________________ has applied for volunteer work the MS National Guard Youth
(Print name of Potential Mentor)
ChalleNGe Academy, which focuses on the needs of young adults. This Potential Mentor is being
considered for a position with one of our applicants. We would like your help in learning more about this
person. Please answer all questions on this form to the best of your knowledge and opinion. All information
received will be confidential.
How long have you know the Potential Mentor? __________ In what way?________________
Does the Potential Mentor have a good home relationship? ______________________________
Does the Potential Mentor work well with others? _____________________________________
How would you rate the Potential Mentor concerning:
Personal Habits
 Excellent
 Good
 Average
 Poor
Character
 Excellent
 Good
 Average
 Poor
Morals
 Excellent
 Good
 Average
 Poor
Compassion for others
 Excellent
 Good
 Average
 Poor
Completes Commitments
 Excellent
 Good
 Average
 Poor
Emotionally Stable
 Excellent
 Good
 Average
 Poor
Receives Constructive
Criticism
 Excellent
 Good
 Average
 Poor
Health
 Excellent
 Good
 Average
 Poor
Additional Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
Print Name of person giving reference: ______________________________ Cell Phone: _______________
Home Phone: ___________________ Email Address:____________________________________________
Signature of person giving reference: ________________________________
Date: _________________
This application version supersedes all previous versions. Please destroy earlier versions. Local reproduction authorized.
Revised April 2014
Questionnaire for Potential Mentor
Today’s Date: __________________
Applicant’s Name: ______________________________________________________________
Potential Mentor’s Name: ________________________________________________________
1. As the potential mentor, what are your plans for keeping this applicant on a positive path?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2. What are your expectations in this relationship?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3. On a scale of 1 to 10, with 10 being great self control, how would you rate yourself on your ability to
deal with stress? _______ How would your peers rate you? _______
4. Are there any plans of relocating outside of Mississippi within the next 12 months?_______ If so, for
what reason are you relocating? ________________________________________
5. What is your prior work experience with young adults?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________
6. Should the program need to contact you for any reason, when would you prefer to be called and what is
the best number to reach you. _________________________________________
7. Will you be able to attend the “MANDATORY” Mentor Training Day, at Camp Shelby, on an assigned
Saturday?
○ YES
○ No
8. Are there any questions or comments you would like to express?
___________________________________________________________________________
This application version supersedes all previous versions. Please destroy earlier versions. Local reproduction authorized.
Revised January 2012
City of Petal
P
P
DEPARTMENT OF POLICE
127 W 8th Avenue
Petal, MS 39465
601-544-5331
D
601-544-5347 {Fax}
__________________________________________________________________
I, _______________________________________ hereby authorize the
(Potential Mentor Name: Print)
Petal Police Department to check all of the department’s records, for use as a
criminal history background check. I also authorize the following person, business
or organization to receive a copy of this background check.
MS Youth Challenge Academy
Building 80, West Jackson Avenue
ATTN: RPM Department
Camp Shelby, MS 39407-5500
601-558-2621
_______________________________
SIGNATURE
_______________________________
DATE
City of Petal
P
DEPARTMENT OF POLICE
127 W 8th Avenue
P
Petal, MS 39465
601-544-5331
D
601-544-5347 {Fax}
__________________________________________________________________
Criminal History Background Check
Name (printed): ____________________________________________________
Date of Birth: ______________________________________________________
Driver’s License Number: ____________________________________________
State Issued: _______________________________________________________
___________ Criminal History Found
___________ No Criminal History Found
Signature and title of official conducting background check:
__________________________________________________________________
Date of Background Check
_______________________