mentorapplication

Witherspoon Institute Application

MENTORSHIP INFORMATION

Part One (1)

First Name:

Last Name:

Title:

Organization:

Work Phone:

Work Address:

City: State: Zip:

Home Phone: Cell:

Home Address:

City: State: Zip:

Ethnicity:

Email address:

Please choose your career fields or interests by marking 1 through 4 for choices:

Educational Background:

Previous experiences with youth:

(Scouts, church, community)

Have you ever been a mentor?

If so, please describe your experience.

Please indicate any of the activities below that interest you. List others in the blank spaces.

Personal References 1:

Name: Last:

Phone:

Address:

City: State: Zip:

Personal References 2:

Name: Last:

Phone:

Address:

City: State: Zip:

1. The preferred gender of your mentee:

2. The preferred age of your mentee: (select one)

3. Specific day and time frame you are available: (select as many as applies)

Days:

Evenings:

4. Why are you interested in becoming a Witherspoon Institute mentor?

5. Please describe your hobbies and interests:

6. Please describe your occupation:

7. What support or training do you think you will need to be a successful mentor?

8. Describe the kind of student with whom you would like to be matched.

9. How did you hear about the program?

This information insures that all persons at our school site can be identified at all times.

Soc. Sec. Number:

Driver’s Lic. DOB:

Height: Weight: Eyes: Hair:

Notify in case of emergency- Name:

Phone:

Signature: Date:

Witherspoon Institute protocol requires we complete a background check for mentors working directly with children. We will process backgrounds for criminal violations only.

I, (Name) , authorize the Witherspoon Institute to conduct

a background check.

Have you ever been convicted of a felony?

If yes, please describe:

Signature:

Date:

WELCOME!

We appreciate your interest in the Witherspoon Institute Ambassador’s Mentorship Program (AMP). AMP evolved out of the 2008 program year in which the Alpha Kappa Alpha fraternal organization acted as mentors at the Witherspoon Brockton YMCA youth site. There was marked contrast of support for the 20 youth who participated in that site compared with the other 3 sites located throughout Greater Boston. In fact, the Brockton site was so effective we began to adopt mentorship methodologies at a second site which bolstered the remaining 3 concluding weeks and flourished successfully.

Our post season determination was to build mentorship into the structure of the program. During the eight week course experience, the mentors will help scholars with public speaking, essay writing, public protocol including forms of address and personal and business etiquette. As last year, the bonds built leave indelible impressions upon the scholars as witnessed at the programs finally at the formal children’s ball.

The Witherspoon Ambassadors program serves to bridge the connection between younger and older generations by creating building blocks for future leaders to stand on the experience of the individual and collective community. Opportunities to work with youth throughout Massachusetts are currently being determined for the upcoming season. As sites are being selected, please inquire about Witherspoon Institute classes listed in the city you work or live in today. To this end, we invitie you to help identify familiar orgainizations that may wish to participate in our youth program. We are looking forward to motivated mentors to apply from the corporate community as well as local communities from which the scholars reside. We are enthusiastic to receive your applications and welcome you to join the Witherspoon family.

Mentorship Application

Teachers Inquiry Form