Mentor Application

Community Pillars Mentorship Programme

Grounding today’s youth to be the pillars of tomorrow’s society

Apply for Mentorship

CONTACT INFORMATION

Name

Date

Address

Parish

Country

Home Phone

Work Phone

Mobile

Email Address

Barbados National ID No

Date of Birth

Gender

Male Female

Please list All Members of Your Household:

Name

Sex

Age

Relationship to Applicant

Name 1

Male Female

Age 1

Relationship to Applicant 1

Name 2

Male Female

Age 2

Relationship to Applicant 2

Name 3

Male Female

Age 3

Relationship to Applicant 3

Name 4

Male Female

Age 4

Relationship to Applicant 4

Name 5

Male Female

Age 5

Relationship to Applicant 5

Employment History

Please provide employment information for the past five years, with most recent position held first. If more space is needed use an extra sheet of paper.

1st Employer

Employer

Address

Supervisor's Name

Supervisor's Title

Period of Employment From

Period of Employment To

Position Held

2nd Employer

Employer

Address

Supervisor's Name

Supervisor's Title

Period of Employment From

Period of Employment To

Position Held

3rd Employer

Employer

Address

Supervisor's Name

Supervisor's Title

Period of Employment From

Period of Employment To

Position Held

Applicant Questions

Please answer all of the following questions as completely as possible.

1. Why do you want to become a Mentor?

2. Do you have any previous experience Mentoring or working with youth? If so, please specify.

3. What qualities, skills, or other attributes do you feel you have that would benefit a young person? Please explain.

4. Can you commit to participate in the Community Pillars Mentorship Programme for a minimum of nine (9) months from the time you are matched with a young person?

5. Are you available to meet with your mentee four hours per month and have contact at least once per week? Please explain any particular scheduling issues.

6. Describe your general health. Are you currently under a physician’s care or taking any medications? Yes No If so, please explain.

7. How would you describe yourself as a person?

8. How would your friends, family, and co-workers describe you?

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

10. Have you ever used illegal drugs? Yes No If so, what substances were used and how often?

11. Are you currently using any illegal drugs or controlled substances? Yes No If so, what substances are used and how often?

12. Do you drink alcoholic beverages? Yes No If so, what and how often?

13. Have you ever been convicted of driving while under the influence of alcohol? Yes No If yes, when and what were the circumstances?

14. Do you use tobacco products? Yes No If so, what and how often?

15. Have you ever received treatment for alcohol or substance abuse? Yes No If yes, please explain.

16. Have you ever been treated or hospitalized for a mental disorder? Yes No If yes, please explain.

17. Have you ever been investigated or convicted of child abuse or neglect? Yes No If yes, please explain.

18. Have you ever been investigated or convicted of sexually abusing or molesting a youth 18 or younger? Yes No If yes, please explain.

19. Are you willing to communicate regularly and openly with program staff, provide monthly information regarding your Mentoring activities, and receive feedback regarding any difficulties during your participation in the Mentoring program?

20. Are you willing to attend an initial Mentor training session and in-service training sessions after being matched?

Signing

Please read this carefully before signing:

Community Pillars Mentorship Programme appreciates your interest in becoming a Mentor.

Please initial each of the following:

I agree to follow all Mentoring program guidelines and understand that any violation will result in suspension and/or termination of the Mentoring relationship.

I understand that the coordinators of the Community Pillars Mentorship Programme are not obligated to provide a reason for their decision in accepting or rejecting me as a Mentor.

(optional) I agree to allow Community Pillars Mentorship to use any photographic image of me taken while participating in the Mentoring program. These images may be used in promotions or other related marketing materials.

I understand I must return all of the following completed items along with this application, and that any incomplete information will result in the delay of my application being processed:

Copy of your valid driver’s license and proof of auto insurance
Information Release Form
Personal References Form
Interest Survey Form
Certificate of Character

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

Driver's License

Proof of Auto Insurance

Signature

Date

Please return or email this application and the items listed above to the Barbados Probation Department #33 Roebuck Street, Bridgetown.
Email – probation.department@barbados.gov.bb

Information Release

I understand it will be necessary for the Community Pillars Mentorship Programme to conduct a background check regarding my driving record, criminal history, personal references, and employment. I authorize Community Pillars Mentorship Programme to obtain any needed information regarding my driving record, legal/criminal history, character references, and employment from any agency, my employer, and personal references for the purposes of participating in a Mentoring program. Further, I provide permission for Community Pillars Mentorship Programme to conduct the same investigation of my background in previous countries in which I have resided. Further, I understand that information about me will be anonymously (without my name) shared with a prospective mentee(s) and his/her parent(s)/guardian(s) to aid in determining a suitable match. Once a Mentor/Mentee match is determined, my identity and any other information known about me may be shared with the Mentee and parent/guardian to ensure and aid in facilitating a safe and successful match relationship.

Signature

Date

Full Name

Address

Parish

Country

Date of Birth

Barbados National ID No.

Personal References

Please list the names, addresses, and phone numbers of three people you would like to use as character references (only person whom you have known for at least a year). Include at least one relative. Any information Community Pillars Mentorship Programme gathers from these references will be held as confidential and not released to you, the applicant.

1st Reference

Name

Address

Parish

Country

Phone

Phone 2

Relationship

How Long Known

2nd Reference

Name

Address

Parish

Country

Phone

Phone 2

Relationship

How Long Known

3rd Reference

Name

Address

Parish

Country

Phone

Phone 2

Relationship

How Long Known

Mentor Interest Survey

Name

Date

What are the most convenient times for you to meet with your mentee? Please check all that apply.

Do you speak any languages other than English? If so, which languages?

Would you be willing to work with a child who has disabilities? If so, please specify disabilities you would be willing to work with.

What are some favorite things you like to do with other people?

What are your favorite subjects to read about?

What is your job and how did you choose this field?

What is one goal you have set for the future?

If you could learn something new, what would it be?

What person do you most admire and why?

Describe your ideal Saturday.

List any other areas of strong interest:

Mentor Contract

Name

Date

By choosing to participate in the Community Pillars Mentorship Programme, I agree to:

Follow all rules and guidelines as outlined by the Programme Coordinator, Mentor training, program policies, and this contract.
Be flexible and provide the necessary support and advice to help my Mentee succeed.
Make a nine (9) month commitment to being matched with my mentee.
Meet at least four hours per month with my mentee.
Make at least weekly contact with my mentee.
Obtain parent/guardian permission for all meeting times at least three days in advance, if possible.
Be on time for scheduled meetings or call my Mentee at least 24 hours beforehand if I am unable to make a meeting.
Submit monthly meeting times and activities to the Programme Coordinator, and regularly and openly communicate with the Programme Coordinator as requested.
Inform the Programme Coordinator of any difficulties or areas of concern that may arise in the relationship.
Keep any information that my Mentee tells me confidential except as may cause him/her or others harm.
Always obey traffic laws when in the presence of my Mentee.
Never be in the presence of my Mentee when I have or am consuming alcohol, tobacco, or controlled substances.
Participate in a closure process when that time comes.
Notify the Programme Coordinator if I have any changes in address, phone number, or employment status
Attend Mentor training sessions as required.

I understand that upon match closure, future contact with my Mentee is beyond the scope of the Community Pillars Programme and may happen only by the mutual consensus of the Mentor, the mentee, and parent/guardian.

I agree to follow all the above stipulations of this programme as well as any other conditions as instructed by the Programme Coordinator at this time or in the future.

Signature

Date

Community Pillars Mentorship Programme