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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: ______________________________
_______________________________________________________________________
_
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)
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
Other (please specify): ___________________

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Application

  • 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. _______________________________________________________________________ _ 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. 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. Other (please specify): ___________________