Mentor Application 2012-2013

All information will be kept confidential and must be provided for this application to be considered complete.

Personal Information
First Name Preferred/Nickname Middle Name Last Name

_________________
Email Address

_________________ __________________ ____________________

Social Networks You Use Facebook LinkedIn Smart Phone? Yes No Twitter Other

_______________________________________________
Home Phone
example: 555-555-5555

______

Cell Phone

example: 555-555-5555

Text Messaging? Yes No

____________________
Current Address

____________________

_______________________________________________
City State Zip Code

Preferred Method of Contact Home Phone Email Cell Phone

_________________________ ______ __________

Birth Date Gender Male Female Marital Status Single Married Divorced Widowed

example: 01/01/11

___________________
Race Pacic Islander Hispanic/Latino

Black/African-American American Indian/Native American

Caucasian Asian Descent Citizenship

Other

__________

Languages English Spanish Other

US Citizen Non-Citizen
1

Permanent Resident

__________

Educational & Work Information

Secondary Education Middle School Name Location
City, State

____________________________
High School Name

____________________________
Location
City, State

Graduation Year

____________________________
Undergraduate Information University Name
example: University of Virginia

____________________________

______________

Educational Goals Associates Degree Bachelors Degree Masters Degree MBA Cumulative GPA Ph.D. M.D.

_________________________________________________________
Current Year
example: Junior, Senior

Expected Graduation Date

example: 01/12

____________________
Major(s)

____________________
Minor(s)

example: Biology

____________________

____________________

__________

J.D. D.M.D. Other

If applicable: Graduate Information University Name

example: University of Connecticut

_______

_________________________________________________________
Expected Degree
example: Masters, Doctorate

Degree Title
example: Biomedical Engineering

____________________________
Current Year
example: First Year example: 01/12

____________________________
Cumulative GPA

Expected Graduation Date

____________________

____________________

__________

If applicable: Work Information Current Organization/Company Current Position

___________________________________________
Time in position

__________________________

example: 2 years 5 months

__________________
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Professional Afliations NSBE SWE SHPE WiMSE/WISE AIChE ASCE BMES IEEE ITE SFB SPIE ACM ACS ASCB APS NTA NAM AMSA ASDA LSAMP Other

__________

Mentor Matching
Why do you want to be a mentor?
max 500 characters

Which grade level(s) would you be most comfortable mentoring? 9th grade 10th grade 11th grade 12th grade No preference

You may need to provide academic support for your mentee. Which areas are you most comfortable with? Math __________
specify

Writing Reading

Athletics Arts/Music/Dance

Organizational Skills Special Subject

Other

__________

Science _________
specify

How did you hear about ManyMentors? Brochure Flyer/Poster Facebook Email Presentation Internet Search Friend Other

__________

Referrals
Do you know other people who might be interested in being a Mentor or Mentee? (all schools are eligible) Mentor Mentee Mentor Mentee Mentor Mentee Name:

______________________________________________

Email Address: ___________________________________________ Name:

______________________________________________

Email Address: ___________________________________________ Name:

______________________________________________
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Email Address: ___________________________________________

Mentoring Opportunities
Are you interested in being: online mentor in-person mentor No preference both

If you are interested in being an in-person mentor, please indicate the mentoring opportunities in which you are interested. For details please see pages 6-8.

Organization

Location

Students

Role Help students complete STEMbased projects

Commitment Every other Wednesday 3:15-4:50pm

Transportation gas reimbursement (transportation may be provided)

STARBASE 2.0

East Hartford

6th grade students

STARBASE

Hartford

5th grade students

Help students complete STEMbased projects; give class presentations about your major/ research/future career

variable

gas reimbursement (transportation may be provided)

WAYCMP

New Haven

10-12th grade students

Help students with Four Saturday college meetings from preparedness, 9-12pm career exploration, spanning and exposure to October-March STEM elds

gas reimbursement (transportation may be provided)

Granville Academy

8th grade Waterbury students

Help students learn Algebra by leading mathbased projects; Help students with invention design

Every other Tuesday 6:00-8:00pm

gas reimbursement (transportation may be provided)

CPEP

various

5th-8th grade students

Give class presentations about your major/ research/future 4 career

TBD

gas reimbursement (transportation may be provided)

Supplemental Documents In addition to this application, I am emailing my resume (optional) and mailing my transcript (required) to ManyMentors for review. ManyMentors Agreement As a ManyMentors Mentor I agree to: 1. Spend at least one semester as a Mentor 2. Be available for scheduled online meetings unless prior notication is sent 3. Attend the ManyMentors orientation and three mandatory mentor trainings per semester 4. Pass a background check and comply with program policies.

By submitting this application, I afrm that the facts set forth in it are true and complete. I understand that if I am accepted as a Mentor, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
Name (type) Date

______________________________________

__________

Please click SUBMIT on the rst page to send off your application!

Thank you for completing this application form and for your interest in becoming a ManyMentors Mentor!

Send additional documents to apply@manymentors.org or 1077 Silas Dean Highway, Suite 200 Wetherseld, CT 06109

Mentoring Opportunities 2012-2013

STARBASE
STARBASE 2.0 Program Site: 777 Burnside Avenue, East Hartford, CT Description: STARBASE 2.0 is an afterschool program that provides underprivileged 6th grade students that have graduated from the regular STARBASE program with the next steps to pursue their interests in STEM. STEMentor Role: Small teams of mentors will aid the students in completing a STEM-based project as well as participate in team building and characterbuilding activities. Projects include but are not limited to: video editing, video game design, and solar cars. Commitment: Mentors are asked to participate in no less than 8 and up to 14 face-to-face meetings when mentees at East Hartford Middle School. The meetings will take place afterschool between the times of 3:15-4:50pm every other Wednesday between October and May, excluding school vacations. While consistent participation is encouraged, due to the team mentoring style there is reasonable flexibility to accommodate for Mentor schedules. Summary: Modest time commitment, travel required (gas reimbursement available), little to no material preparation required, work with 6th grade underprivileged students from the East Hartford school district.

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STARBASE Program Site: 251 Maxim Rd. Hartford, CT and/or online Description: STARBASE is a during the school day program that provides under-privileged 5th grade students with week-long intensive STEM program at the STARBASE site. STEMentor Role: Mentors will help small groups of students (approx. 5) understand and complete STARBASE led projects. Mentors will also have opportunities to talk with the class about their major, anticipated career, and other STEM-related content. Virtual STEMentor Role: Mentors can connect with a STARBASE class for a video teleconferencing visit and present STEM-based material to increase student interest in the field (ie: what the mentor is studying and how it relates to STEM). The presentations can be formal or informal, but ManyMentors staff must approve the content prior to the classroom sessions. Commitment: Mentors are asked to participate in at least 3 classroom sessions, but can participate more if desired, as coordinated by ManyMentors and STARBASE staff. Sessions take place during the day between the hours of 9:30am 1:30pm between October and early June, excluding school vacations. Summary: Flexible time commitment, travel may or may not be required (gas reimbursement available), variable material preparation required, work with 5th grade underprivileged students from the East Hartford school system.

Workforce Alliance Youth Mentoring Program (WAYCMP)

Program Site: 560 Ella Grasso Blvd New Haven, CT and/or online Description: The Youth Council's mentorship program seeks to promote the pursuit of post-secondary education while giving high school students some tangible experience of college life. The mentorship program will foster relationships between college students and high school students in an educational, professional, and informal atmosphere. STEMentor Role: Mentors will be matched and interact with WAYCMP mentees during a October 20th 2012 Meet-n-Greet event at the WAYMP site. Following the initial meeting, mentors are expected to use provided online communication tools and suggested conversation topics to stay in contact with their mentee at least biweekly thru the second and third meeting dates, Feburary 2nd 2013 and March 30th 2013, respectively. Finally, mentors are asked to participate in the

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planning, development, and running of a weekend-long STEM-University (STEMU) event at UConn. Tentatively scheduled for May 4th 2013, this event will be designed to expose mentees to STEM-related activities, research, career opportunities, as well as UConn and college life overall. Commitment: Mentors are required to attend the scheduled events and maintain online communication with mentees in the interim. The program takes place between October 2012 May 2013. Summary: Four required time commitments, travel required (gas reimbursement available), modest material preparation required (only for the STEM-U event), work with 10-12th grade underprivileged and underrepresented students from the New Haven school system.

Granville Academy
Program Site: 16 South Elm Street Waterbury, CT Description: Granville Academy is an afterschool program that primarily educates and mentors inner-city youth in grades 5 through 12 with fundamental skills in business, finance, science and engineering. STEMentor Role: Mentors will develop and lead engaging, interactive, hands-on STEM-based activities to teach middle school Granville students about important principles within the STEM field while drawing correlations to the real world applications. Invention Convention Mentor Role: Mentors will interact with the middle school Granville students to guide the idea generation, concept evaluation, and final design and development of an invention to be entered in the annual Connecticut Invention Convention Competition. Commitment: Mentors will be asked to participate in 2-3 person teams in up to 14 classroom sessions on a rotating schedule with other mentor teams at the Granville site. The meetings will take place afterschool between the times of 6:00-8:00pm every other Tuesday between October and May, excluding school vacations. While consistent participation is encouraged, due to the team mentoring style there is reasonable flexibility to accommodate for Mentor schedules. Summary: Modest time commitment, travel required (gas reimbursements provided), material preparation required, work with 5-8th grade underrepresented students from the Waterbury school district.

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Catalysts Powering Educational Performance (CPEP) After School Challenge Program

Program Site: Various schools in the Bloomfield, Bridgeport, Bristol, Danbury, Hartford, New Britain, New Haven, Norwalk, Stamford, and Waterbury districts Description: CPEP After School Challenge Program provides relevant and rigorous academic enrichment as well as a host of critical 21st century competencies, including team building and critical thinking. Students work together on teams to build a variety of hands-on CPEP projects using the engineering design process to develop the most effective and efficient project designs. The capstone activity takes place at CPEP Day; which was held on May 4, 2013 at the Connecticut Convention Center in Hartford. STEMentor Role: Mentors will serve as STEM advocates by giving classroom presentations on STEM-based material to increase student interest in the field (ie: what the mentor is studying and how it relates to STEM). The presentations can be formal or informal, but ManyMentors staff must approve the content prior to the classroom sessions. Commitment: Mentors can schedule each presentation through the ManyMentors staff. The presentation will take place at the selected school location on the selected day between 3:00-4:00 or 4:00-5:00pm. Summary: Small time commitment, travel required (gas reimbursements provided), material preparation required, work with 5-8th grade underrepresented students all over the State of Connecticut.

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