Mentoring Partnership of Minnesota - Program Information Form

Mentoring Partnership of Minnesota

Program Information Form

Welcome and thank you for filling out a Program Information Form. The information you provide us will be used to create a profile for your organization that will be added to our searchable online database. The database is a great referral system for potential volunteers to sign up with a program. On average, we receive 35 inquiries each month from adults looking to volunteer with youth. The more information you provide us, the better we are able to serve you.

By providing and maintaining your current information, you will also receive our monthly e-newsletter which features upcoming trainings and funding opportunities, public policy updates and marketing and promotional materials to use in your own recruitment efforts.

Program Name

Organization Name (If different than above.)

Program Address

City

State

Zip code

First Name

Last Name

Phone Number

Program Email

Web Address

Regions Served (Check all that apply)

Metro Area
Northern MN
Southern MN
Out of State*

* "Out of State" option intended for communities in states near or bordering MN, that do not currently have a state mentoring partnership. To find your state mentoring partnership, visit www.mentoring.org.

Counties Served (Check all that apply)

Aitkin
Anoka
Becker
Beltrami
Benton
Big Stone
Blue Earth
Brown
Carlton
Carver
Cass
Chippewa
Chisago
Clay
Clearwater
Cook
Cottonwood
Crow Wing
Dakota
Dodge
Douglas
Faribault
Fillmore
Freeborn
Goodhue
Grant
Hennepin
Houston
Hubbard
Isanti
Itasca
Jackson
Kanabec
Kandiyohi
Kittson
Koochiching
Lac Qui Parle
Lake
Lake of the Woods
Le Sueur
Lincoln
Lyon
Mahnomen
Marshall
Martin
McLeod
Meeker
Mille Lacs
Morrison
Mower
Murray
Nicollet
Nobles
Norman
Olmsted
Otter Tail
Pennington
Pine
Pipestone
Polk
Pope
Ramsey
Red Lake
Redwood
Renville
Rice
Rock
Roseau
Scott
Sherburne
Sibley
St. Louis
Stearns
Steele
Stevens
Swift
Todd
Traverse
Wabasha
Wadena
Waseca
Washington
Watonwan
Wilkin
Winona
Wright
Yellow Medicine
Out of State

Briefly describe the program and your goals.

Check all that describe your program

Adult to Adult
Adult to Youth
Community-Based
E-Mentoring
Faith-Based
Family (volunteer working with family/family to family)
Group (one or more adult(s) working with a group of youth)
One to One
Peer to Peer Mentoring
School-Based
Team (at least 2 adults)
Treatment/Mental Health Facility
Workplace
Other

If other, please describe:

YOUTH/MENTEES

What is the age range of youth served?

Under 5 years
5-10 years
11-14 years
15-18 years
Older than 18 years
No specific age

Describe characteristics of youth served: (Please include any program requirements or special needs)

How are youth typically referred to your mentoring program?

Self referral
Parent referral
Social worker referral
Teacher referral
Other professional referral
Court ordered

How do youth initially come in contact with your mentoring program?

Youth application form
Youth interview
Youth orientation training
Parent/Guardian Permission form
Parent/Guardian orientation training
Home visit

MENTORS/VOLUNTEERS

Describe desired characteristics of mentors/volunteers referred to the program:

Length of volunteer time commitment required:

3-6 months
7-9 months
10-12 months
More than 12 months
There is no minimum length of commitment

Frequency of mentor/youth activities:

Once a month
2-3 times a month
4 times a month
Other

Briefly describe the mentor/volunteer job description: (Include expectations, level of physical activity, special skills desired, and benefits for the mentor)

Does the program have a youth/mentee waiting list?

Yes
No

Check all that apply to the volunteer screening process:

Application
Interview
Reference checks
Home visits
State criminal background checks
Federal criminal background checks
Personality tests
SafetyNet
Child abuse registry
Driving records checks
Other

Check all the steps your program takes to protect/support participants:

Home visits
Liability insurance
On-site programming
Child/adult ratio rules
Training

Describe the types of training offered to the volunteer for support?

What is the best time to refer volunteers to the program?

Spring
Summer
Fall
Winter
Anytime

Briefly describe your reasons for signing up on this form, and add any other comments.

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Update your Program Contacts Here

Mentoring Partnership of Minnesota - 81 South Ninth Street, Suite 200 - Minneapolis, MN 55402
612.370.9180 - mentor@mentoringworks.org
MENTOR