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Mentor acceptance form 525
Mentor acceptance form 525
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Application

  1. 1. Somerset Connect Mentoring Program Mentor Application 2012-2013 Personal Information Name: _________________________________________________________________ (Last, First) Mailing Address: _________________________________________________ P.O. Box or Street Address Apt. # _________________________________________________ City State Zip Preferred Phone: (_____) -_____-_____ E-mail: ___________________________ Agency: ____________________________ Employment Status: P/T F/T (Business, agency, faith, civic group on whose behalf you are volunteering of as an individual) Student Current Employer: ________________________________________________ (IF RETIREE, list company retired from) Employer Address: ________________________________________________ Street City State Zip The following information will help aid with matching mentors with students. Age: ______ Gender: __________ Racial/Ethnic Origin: African American/ Black Hispanic/Latino American Indian/Alaskan White Asian/Pacific Islander Other (specify) ____________________________ Special Skills/Hobbies/Interests/Experiences: ______________________________
  2. 2. _______________________________________________________________________ _ Do you have any children or grandchildren in Somerset County Public Schools? Child’s Name: ___________________________________________________________ School: _____________________________________ Grade:_____________________ School Choices Please indicate your FIRST (#1), SECOND (#2) choices of school/grade level Pre-Kindergarten through Fifth Grade: _____ Carter G. Woodson Elementary (Crisfield, MD) _____ Deal Island Elementary (Deal Island, MD) _____ Ewell Elementary (Ewell, MD) _____ Greenwood Elementary (Princess Anne, MD) _____ Princess Anne Elementary (Princess Anne, MD) Sixth and Seventh Grades: _____ Somerset Intermediate (Westover, MD) Eighth through Twelfth Grade: _____ Crisfield Academy/High School (Crisfield, MD) _____ Marion Sarah Peyton Adult & Promise Academy (Marion, MD) _____ Washington Academy/High School (Princess Anne, MD) Additional Comments: ___________________________________________________ Gender Preference: Male Female No Preference *The student needs one hour of your time once a week for the entire school year.* What days are you available? M T W TH F (Circle all that apply) What time of day are you available? Morning Mid-day Afternoons (Circle all that apply)
  3. 3. The Mentor Coordinator will contact you to schedule an orientation. Mentor Agreement As a mentor I will: 1. Attend scheduled orientation as provided by the Mentor Coordinator and assume responsibility for familiarizing myself with and observing the rules and policies of the school(s). 2. Sign in and out as designated at your placement school including the accurate time for each day served. 3. Maintain and uphold the highest standards of professionalism and moral conduct when working with students, as well as when representing SCPS in the community. 4. Maintain strict confidentiality of sensitive information. 5. Perform my duties and responsibilities to the best of my ability. By singing below, I affirm that the information provided in this application is true and correct to the best of my knowledge. I understand the information provided on this form may be used to conduct criminal background screening if deemed necessary. Any falsification on this application may result in termination of the school-mentor relationships. I also understand that the school principal has the authority to terminate any volunteer, without appeal, if he or she feels it is in the best interest of the students and school to do so. I agree to a criminal background screening and fingerprinting. ______________________________________ ____________ Applicant’s Printed Name Date ______________________________________ Applicant’s Signature How did you hear about us? Your place of employment Please send this application to: An educator Mentor Coordinator Another mentor 7982A Tawes Campus Drive Westover, Maryland 21871 Through your university
  4. 4. Other (please specify): ___________________

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