What is EMPOwERgirlz?
The EMPOwERgirlz Youth Mentoring and Leadership Development program serves girls between the ages of 6 – 17. Our vision is to Empower young girls through Mentoring, Prevention, Opportunities,
Education, and leadership while providing access to Resources that foster self-realization, academic excellence and optimal health and wellbeing. Program participants are exposed to educational workshops, STEM programs, community service projects, mentoring and tutoring services in order to develop a commitment to academic success, foster essential life skills, develop an understanding of healthy and respectful relationships, and increase the awareness of social issues while building their self- esteem.
Our areas of focus include:
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Academic Performance Enhancement

Science, Technology, Engineering, Arts & Math (STEAM)

Health and Well-Being

Civic Engagement and Leadership Development

Diversity and Racial Justice Empowerment
 College Readiness and Career Development
Want to make a difference? Become a mentor today!
 Group mentoring sessions are every other Saturday, September 2015 - May 2016, 9am – 2:30pm
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Meetings take place at the YWCA NCA (2303 14 th Street NW).
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Mentors arrive by 8:45am and depart when their mentees are dismissed for the day.
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Mentors are encouraged to attend all EMPOwERgirlz Saturday sessions as well as interact with their mentees on a weekly basis outside of the program to build and maintain meaningful relationships with their mentees.
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Mentors participate in an interview, complete criminal background check and child abuse clearances, attend an orientation and meet and greet to get started!
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YWCA offers four mandatory in-service trainings to support your relationship with your mentee.
This is your chance to invest in the life of a young girl while developing marketable leadership skills.
As a mentor, you can make a difference in the lives of DC Metro Area youth! Join TODAY!
If this is an opportunity that you are interested in, please complete the form below and e-mail it to twilliams@ywcanca.org.
We look forward to hearing from you!
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YWCA National Capital Area | 2303 14 th St. NW, Ste. 100 | Washington, DC 20009 | P 202.626.0700 | F 202.347.7381 | www.ywcanca.org

Thursday, July 30, 2015
6:00pm – 7:00pm
Friday, August 21, 2015
Monday, August 24, 2015
6:00pm – 7:30pm
Thursday, September 3, 2015
6:00pm – 7:30pm
Thursday, September 10, 2015
6:00pm – 8:00pm
Saturday, September 19, 2015
8:45am – 3:00pm Mentors
Saturday, September 26, 2015
8:45am – 3:00pm Mentors
Saturday, October 10, 2015
8:45am – 3:00pm Mentors
Friday, October 16, 2015
5:00pm – 7:00pm
Saturday, October 24, 2015
8:45am – 3:00pm Mentors
Saturday, November 7, 2015
8:45am – 3:00pm Mentors
Wednesday, November 18, 2015
6:00pm – 7:30pm
Saturday, November 21, 2015
8:45am – 3:00pm Mentors
Saturday, December 5, 2015
8:45am – 3:00pm Mentors
Saturday, January 23, 2016
10:00am – 2:00pm TENTATIVE
Saturday, February 6, 2016
8:45am – 3:00pm Mentors
TBD (February)
EMPOwERgirlz Information Session at YWCA NCA
Mentor Applications Due
In-Service Training: Relationship Development (MANDATORY) at YWCA NCA Hosted by: BEST Kids
Mentor Orientation at YWCA NCA (MANDATORY)
EMPOwERgirlz Mixer at YWCA NCA (MANDATORY)
EMPOwERgirlz Session 1
EMPOwERgirlz Session 2
EMPOwERgirlz Session 3
Mentor-Mentee Outing at TBD
EMPOwERgirlz Session 4
EMPOwERgirlz Session 5
In-Service Training: Realistic Goal Setting (MANDATORY) at YWCA NCA Hosted by: BEST Kids
EMPOwERgirlz Session 6
EMPOwERgirlz Session 7
Mid-Year Orientation/Mixer (New Participants)
EMPOwERgirlz Session 8
In-Service Training: Conflict Management (MANDATORY)
at YWCA NCA
Saturday, February 20, 2016
8:45am – 3:00pm Mentors
Saturday, March 5, 2016
8:45am – 3:00pm Mentors
Saturday, March 26, 2016
8:45am – 3:00pm Mentors
TBD (April)
EMPOwERgirlz Session 9
EMPOwERgirlz Session 10
EMPOwERgirlz Session 11
In Service Training: Healthy Closure (MANDATORY)
at YWCA NCA
Saturday, April 9, 2016
8:45am – 3:00pm Mentors
Saturday, April 23, 2016
10:00am – 2:00pm
Saturday, April 30, 2016
8:45am – 3:00pm Mentors
Saturday, May 7, 2016
8:45am – 3:00pm Mentors
EMPOwERgirlz Session 12
Mentor/Mentee Outing and Closing Ceremony Rehearsal
at YWCA NCA
EMPOwERgirlz Session 13
EMPOwERgirlz Session 14: Closing Ceremony
YWCA National Capital Area | 2303 14 th St. NW, Ste. 100 | Washington, DC 20009 | P 202.626.0700 | F 202.347.7381 | www.ywcanca.org
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PERSONAL INFORMATION
Name: ______________________________________________________________________________
Date of Birth: ____/____/____ E-Mail: __________________________________________________
Home Address: _______________________________________________________________________
Street City State Zip Code
Ward (circle one): 1 2 3 4 5 6 7 8
Phone Number: (Cell) ____________________________ (Work) _____________________________
Emergency Contact Name: ______________________________________________________________
Emergency Phone Number: _____________________________________________________________
DEMOGRAPHICS
Ethnicity
No, not Hispanic/Latino
Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto
Rican, South or Central American, or Spanish culture or origin regardless of race
Race (Check all that apply)
Asian
Hispanic or Latino
Black or African American
White
American Indian or Alaskan Native
Native Hawaiian or Other Pacific
Islander
Family Information: Income
≤ $9,999
$30,000-$39,000
$10,000 - $19,999
$40,000-$49,999
$60,000 – $69,999 $70,000-$79,999
Size of Household: Number of people living in home
1-2 3
6 7
4
8
$20,000 - $29,999
$50,000 - $59,999
≥$80,000
5
≥9
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YWCA National Capital Area | 2303 14 th St. NW, Ste. 100 | Washington, DC 20009 | P 202.626.0700 | F 202.347.7381 | www.ywcanca.org

HEALTH INFORMATION
Do you have any health conditions or restrictions you think we should be aware of (physical, psychological, allergens, etc.?* _______ Yes ______No
If yes, please describe: _________________________________________________________________
____________________________________________________________________________________
WORK HISTORY
Current Employer: ________________________________ Occupation: __________________________
Circle your level of educational attainment: High School Some College Bachelor’s Masters PhD
College/University Attended/Attending: ______________________________ Graduation Year_______
Major/Minor: ________________________________________________________________________
Are you involved in any other social or civic activities (sororities, volunteer groups, etc)? Yes No
If yes, please list: ______________________________________________________________________
Do you speak any language in addition to English? Yes No
If yes, please list: ______________________________________________________________________
Do you have any previous experience mentoring/volunteering with youth? Yes No
If yes, please explain: __________________________________________________________________
And, for how long (months, years)?_______________________________________________________
Have you ever been arrested or convicted of a crime? Yes No
If yes, please explain: __________________________________________________________________
TRANSPORTATION INFORMATION
Do you have a valid driver’s license?
Do you currently have a vehicle?
Is your vehicle currently insured?
MATCHING INFORMATION
Yes No
Yes No
Yes No
Please rank the following age groups you would like to work with 1-3 (1 being most interested; 3 being the least interested):
_____ Rubies (6 – 9) ______ Sapphires (10 – 13) ______ Pearls (14 – 17) ______No Preference
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YWCA National Capital Area | 2303 14 th St. NW, Ste. 100 | Washington, DC 20009 | P 202.626.0700 | F 202.347.7381 | www.ywcanca.org

Please note briefly why you have chosen to mentor with the EMPOwERgirlz Mentoring Program.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please list any hobbies or special skills: ____________________________________________________
Please list any sports you have played: ____________________________________________________
OPTIONAL:
Would you be interested in leading or coordinating a 90-minute interactive presentation on one of the following subjects? (Check all that apply) o Healthy Relationships o STEAM Activities & Career Exploration o Financial Literacy o Anti-Bullying o o o o
Health & Nutrition
College Readiness
Racial Justice & Diversity
Etiquette Training
Are you interested in serving on the Youth Advisory Council? ______YES ______NO
How did you hear about the EMPOwERgirlz Youth Mentoring and Leadership Development Program?
Friend/Family
Other Agency:___________
Special event
Employer/School
Church
Other:_________________
Library
Poster/ad
Informed Consent
Please read carefully before signing.

I understand that the mentoring program involves attending program sessions (every other Saturday) with mentees for the EMPOwERgirlz academic year from Sept. 2015 – May 2016.
 I understand that I am required to complete criminal background check and submit health screening information to participate in the program.

I understand that I am required to attend an orientation, mixer, and four mandatory trainings.
 I understand that I will only be contacted for a telephone interview, if my application is approved.
“I certify that the facts contained in this application are true and complete to the best of my knowledge.”
Signature: ___________________________________________________ Date: ____________________
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YWCA National Capital Area | 2303 14 th St. NW, Ste. 100 | Washington, DC 20009 | P 202.626.0700 | F 202.347.7381 | www.ywcanca.org

Final application checklist:
____ Completed application
____ Mentor Contract
____ Mentor Matching Questionnaire
____ Criminal Background Check
____ Health Clearance
____ HIPAA Form
____ Photo Release Form
____ Optional: Other Attachments (recommendations, resume’, writing sample, etc.)
Please mail, fax, or email your completed application and signed parent consent forms to:
YWCA NCA National Capital Area - EMPOwERgirlz
2303 14 th St., NW, Suite 100
Washington, DC 20009
T: 202-626-0704
F: 202-347-7381 twilliams@ywcanca.org
Next Steps:

If your application is accepted, we will email you to schedule an interview, preferably in–person.

Upon successful completion of the interview and background check, you will be invited to the
Mandatory Mentor Orientation scheduled for Thursday, September 3 rd at 6:00pm.
FOR OFFICE USE ONLY
Application Mentor
Mentor
Received Contract
Matching
Questionnaire
Health
Clearance
HIPAA
Photo
Release
Optional
Forms
Entered in
Database
Interview
Complete
Background
Check
Complete
Attended
Orientation
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YWCA National Capital Area | 2303 14 th St. NW, Ste. 100 | Washington, DC 20009 | P 202.626.0700 | F 202.347.7381 | www.ywcanca.org