C

1000 Front Street, Suite 366

Uniondale, New York 11553-5015
Office (516)508-3576
Fax: (866)996-1212
Email: TheHipHopMovement12@gmail.com
Website: TheHipHopMovementOneTwo.weebly.com
Keith H. Burgess
Altanya M. Gerald-Burgess
Chief Executive Officer/Project Leader Chief Operations Officer

Cleveland Delaney, Jr.

Program Director

MENTOR APPLICATION
(Please print or write legibly)
Personal Information:
Name______________________________________________________________________________
Gender

O Male

O Female

Date of Birth_________________________________________________________________________
Social Security Number (For Criminal Background Check) _______________________________________
Address _____________________________________________________________________________
Home Phone__________________________________________________________________________
Mobile Phone_________________________________________________________________________
E-mail Phone__________________________________________________________________________
Name/Address of Current Employer_______________________________________________________
_____________________________________________________________________________________
Occupation____________________________________________________________________________

Adapted from materials provided by Mentoring Partnership of Long Island, The ABCs of Mentoring, California Governors Partnership, and
Samaritan House Mentoring Program(January 2011)

Work Phone____________________________________________________________________
Supervisor______________________________________________________________________
Dates of Employment________________________________________________ to Present
Previous Employer(Name and
Address)______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Occupation____________________________________________________________________________
Phone________________________________________________________________________________
Date of Employment______________________________ to ___________________________________
Previous Supervisor_____________________________________________________________________

Volunteer Information:
1. Indicate your age preference: (age also determines length of time mentee will be in
programolder children will be in the program for 1-2 years depending on college plans)

O 10-12

O 13-15

O 16-18

2. What do you feel are your strengths (i.e. language, cultural, math skills, previous volunteer
experiences, etc)
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Adapted from materials provided by Mentoring Partnership of Long Island, The ABCs of Mentoring, California Governors Partnership, and
Samaritan House Mentoring Program(January 2011)

3. Write a brief statement on why you have chosen to participate in a mentoring

program.

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4. Please list the activities you enjoy the most: (ex: listening to music---what kind of music,
photography, reading, playing board games, visiting museums, arts and crafts, cooking,
career explorations, writing, outside activities, playing video games, watching TV shows--please name the shows, watching reality TV---name the shows, etc..
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Adapted from materials provided by Mentoring Partnership of Long Island, The ABCs of Mentoring, California Governors Partnership,
and Samaritan House Mentoring Program(January 2011)

5. Please initial the following statements:

_________ I understand I am required to contact my mentee at least once a week via phone.
_________ I understand I am required to meet with my mentee, on site or during a group
outing, least once a month
__________ I understand I am required to attend 1-2 planning field trips annually, with my
Mentee, other mentors and their mentees.
_________ I understand I will be required to complete 40 hours of initial training and
Quarterly trainings which will be offered by the HIP HOP Movement Summer
Youth Academy.

6.

O Yes

O No

Within the past 10 years, have you been convicted of any felony or

misdemeanor classified as an offense against a person or family, an offense of public

indecency or a violation involving a state/federally controlled substance?

7.

O Yes O No

Are you under current indictment or has a district/county attorney

accepted an official complaint for any offenses in question #6?

8. If the answer is YES to questions 6 or 7, please explain below:

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Adapted from materials provided by Mentoring Partnership of Long Island, The ABCs of Mentoring, California Governors Partnership,
and Samaritan House Mentoring Program(January 2011)

Educational Background:
O Some High School

O Graduate/Professional School

O High School Graduate

O Technical School

O Some College

O College Graduate

O Other (please specify)

___________________________________________________________________________
___________________________________________________________________________
Please list at least four references (please include one family member, one personal friend,
one work reference and a current/prior supervisor):
Name________________________________________________________________________
Address_______________________________________________________________________
______________________________________________________________________________
Phone Number__________________________________________________________________
Relationship____________________________________________________________________

Name________________________________________________________________________
Address_______________________________________________________________________
______________________________________________________________________________
Phone Number__________________________________________________________________
Relationship____________________________________________________________________

Name________________________________________________________________________
Address_______________________________________________________________________
______________________________________________________________________________
Phone Number__________________________________________________________________
Relationship____________________________________________________________________

Adapted from materials provided by Mentoring Partnership of Long Island, The ABCs of Mentoring, California Governors Partnership,
and Samaritan House Mentoring Program(January 2011)

Name________________________________________________________________________
Address______________________________________________________________________
_____________________________________________________________________________
Phone Number_________________________________________________________________
Relationship___________________________________________________________________

Name________________________________________________________________________
Address_______________________________________________________________________
______________________________________________________________________________
Phone Number__________________________________________________________________
Relationship____________________________________________________________________

________________________________
Applicants Signature

___________________
Date

I affirm that the information given in this application is true to the best of my knowledge. I
authorize investigation of all statements made in this application as may be necessary to arrive
at a decision regarding my eligibility for volunteer services. I understand that this investigation
may include a check of the New York State Central Register of child abuse and maltreatment and
a criminal background check. I understand that it is a crime to knowingly falsify any such
information on this form or in any interview and that knowingly falsifying any material
information in this application may automatically disqualify me for the volunteer position.