Step Up Mentor Application
Fall 2015 and/or Spring 2016
Volunteer Mentors are matched with Step Up middle schools students and commit to meeting one-on-one or in small groups during
scheduled mentoring sessions (one 1.5 hour session/ week) for a minimum of one semester. Mentors are encouraged to commit to a full year
if they are able. Mentor orientation and training sessions are provided each fall and spring to help you have a successful and enjoyable time
with your mentee(s)!
_____ STEP UP is my field placement/community service for: _________________________________________________________
Name _____________________________________________ E-mail Address ___________________________________________
Telephone: Cel ________________________________ Home/Local/Other (please specify) ________________________________
Campus/Local Address ________________________________________________________________________________________
Residence Hall/Apt.
Off Campus Address
Home/Permanent Address ______________________________________________________________________________________
Hope ID # (if applicable) __________
Emergency Contact Name/Phone (non-Hope mentors): ______________________________
Educational Status: ____ High School Student
For High School and College Students:
____First Year
____Sophomore
____ College Student
___ HS Graduate/Community Member
____Senior
____Other:_______________________
____ Junior
Name of School:________________________________
College Major __________________________________
Minor ___________________________________
Have you been a mentor with Step Up in the past? If so, when?________________________________________________________
Which clubs and/or organizations are you involved in?: ______________________________________________________________
What do you like to do for fun?: _________________________________________________________________________________
When working on a project, do you enjoy working alone or with others in a small group?____________________________________
Which school subjects (math, reading, science, art, etc.) do you enjoy most?_______________________________________________
Which school subjects do you find most difficult or frustrating?_________________________________________________________
What are a few words your friends might use to describe you?__________________________________________________________
Have you had any experiences with children or youth in mentoring, tutoring or educational programs (paid or volunteer) in the past?
____________________________________________________________________________________________________________
Do you speak another language? If so, which one(s):__________________________________________________________________
What are you looking forward to in mentoring with Step Up?___________________________________________________________
____________________________________________________________________________________________________________
Personal and/or Professional References
Name
Organization or College Dept.
Email or Phone Number
When are you available to mentor? Please select all options that work for your schedule; you will be assigned to one session once you
are matched with your mentee(s).
_____ Wednesdays 3:30-5:00pm
______Thursdays 3:30-5:00pm
_____ Wednesdays 4:00-5:30pm
______Thursdays 5:30-7:00pm
Over
I. STEP UP Mentor Job Description:
STEP UP mentors are one of the most important elements of the STEP UP program. By volunteering to work with
youth, our mentors are providing a vital, caring, one-on-one or small group mentoring relationship that
encourages each student’s potential for success.
STEP UP Mentors will perform the following:
1. Attend Mentor Orientation, In-Service Training, and placement supervision sessions, as required.
2. Mentor one (1) or more afternoon(s) per week for the complete one and a half (1.5) hour each session per semester, unless
otherwise noted (i.e., holidays & breaks) and commit to mentoring at minimum one semester.
3. Be prepared to work by signing in on time and preparing appropriate work materials in advance for student(s).
4. Use mentoring time as instructed by STEP UP staff. Abstain from working on your own homework or other personal activities,
including texting.
5. Encourage positive behavior in youth by modeling good listening skills and promoting an atmosphere of safety, mutual respect,
and acceptance.
6. Complete and submit daily reports for mentoring sessions and semester reports, as requested.
7. Follow the STEP UP daily program schedule.
8. Remain in the designated STEP UP rooms for the duration of each day’s program.
9. Notify the STEP UP office BY NOON if you will be late or unable to mentor on the day scheduled due to illness or emergency.
10. Treat sensitive information from or about your student in a professional manner and follow up with STEP UP staff.
11. Discuss student progress, challenges, and behavioral concerns with STEP UP staff.
12. Follow state laws which require reporting of all abuse and/or neglect to STEP UP staff.
13. Serve as role models for STEP UP students by promoting and displaying appropriate behavior and dress. Inappropriate behavior,
including public intoxication, use of illegal substances, abuse of legal substances, profanity, or harassment will result in immediate
termination.
14. Offer only appropriate comments to students about other adults (i.e. teachers, counselors, parents, and social workers) who provide
support in their lives.
15. Promote the welfare of the STEP UP program by referring questions, concerns, or suggestions to STEP UP staff.
I have read, understood, and agree to follow the above STEP UP Mentor Job Description.
Signature________________________________________________________ Date____________________________
II. Criminal Background Check – All Applicants
READ CAREFULLY --THIS DOCUMENT CONTAINS A RELEASE (non-certified)
As a prospective volunteer of STEP UP, I understand that it is this agency's policy to secure conviction criminal history information as
part of their pre-employment and volunteer participation screening process using the information provided below.
NAME:________________________________________________________________________________________________________
Last
First
Middle
BIRTHDATE:________________________________ RACE:______________________________________ SEX:_______________
I understand that the above information is required by the central records division of the Michigan State Police, Lansing, Michigan. I
authorize and unqualifiedly grant permission to STEP UP and its administration to make inquiries and to obtain any records from child
protection agencies, law enforcement and/or judicial authorities to determine whether any record of criminal conviction exists and whether
there are any felony charges pending against me, including the nature of the offenses. I understand that if I volunteer for STEP UP, this
consent form will become part of my personal file and that any misrepresentation, misleading or untruthful statement, or omission is cause
for dismissal should I become a participant in STEP UP.
I do hereby release STEP UP, its individual Board members, employees, and/or agents from any and all claims and/or liability
whatsoever for any damages or consequences which may result from the pre-employment investigation and/or physical examination,
including the drug screening test (if applicable), related to my consideration for participation in STEP UP programs.
Signature__________________________________________________________ Date ____________________________
III. Publicity Release – All Applicants
I give permission for STEP UP to use my image (photos, digital, video), sound recordings of my voice, and any materials that I submit
during my affiliation with STEP UP.
Signature________________________________________________________ Date ___________________________
IV. Parental Permission – Applicants under age 18 ONLY
I confirm that my child is under the age of 18 and that I give permission for him/her to volunteer as a STEP UP mentor.
Parent/GuardianSignature___________________________________________ Date ___________________________
Return to: STEP UP, 263 College Ave., Hope College Graves Hall B007 PO Box 9000 Holland, MI
49422-9000 Tel. (616)395-7020 Fax (616) 395-7020 stepup@hope.edu www.hope.edu/stepup