OUTAGAMIE COUNTY DIVISION OF YOUTH AND FAMILY SERVICES 500 W. FIFTH STREET APPLETON, WI PHONE (920)

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1 OUTAGAMIE COUNTY DIVISION OF YOUTH AND FAMILY SERVICES 500 W. FIFTH STREET APPLETON, WI PHONE (920) Dear Potential Mentor: OUTAGAMIE COUNTY MENTORING PROGRAM Thank you for your inquiry regarding our Mentoring Program for youth. Enclosed is information about mentoring, an application for the program and our background verification forms. Please take some time to review the information. As a Human Service Agency, we are committed to making successful matches for the youth referred to our program as well as for the mentors. With this in mind, our initial screening and interview process of potential mentors does take some time. But we believe that the time put in the beginning leads to successful matches in the end. The youth referred to our program are between 6-17 years of age. They have been involved in either the Juvenile Justice or Child Welfare System through the Outagamie County Department of Health and Human Services. The goal is to provide at-risk youth with adult mentors who will help youth succeed and prevent further involvement with Health and Human Services. The mentor will develop a positive and trusting relationship with the youth in order to provide support, guidance, consistency, and stability. The mentor will give individual attention to the youth while exposing the youth to new and positive experiences in order to enhance self esteem, improve social skills, and encourage positive problemsolving skills. As a mentor, we would ask that you make at least a 6-month commitment to your mentor match. With all of this in mind, our mentors are provided with 10 hours of training and ongoing support and education to help you be the best possible mentor for the youth. After reviewing the information enclosed, please fill out the questionnaire and other legal forms and return in the self-addressed, stamped envelope provided. Fill out the Records Check form up to the double line; the bottom half will be filled out by said agency. The Background Information Disclosure form needs to be filled out in full. The Vehicle Liability Form needs to be signed by you and your insurance agent. If you have further questions or are in need of further services, please contact a mentor coordinator. We believe that mentors provide a very special service to our youth. They have lasting impressions on the lives of young people who otherwise may get lost somewhere in the system. None of us got where we are alone. Sincerely, Tammy McHugh, CSW Mentoring Program Coordinator mchughtl@co.outagamie.wi.us Nikki Gingras, MSW Mentoring Program Coordinator nikki.gingras@outagamie.org

2 OUTAGAMIE COUNTY MENTORING PROGRAM MENTORING PROGRAM FACT SHEET None of us got where we are alone What is mentoring? Mentoring is a one-to-one relationship overtime, through which an adult fosters the development of character, competence, self-confidence, and self esteem in a young person. It is the empowerment of each youth through the development of his/her abilities through positive, engaging role models. What do mentors do? Give individual attention to youth who may feel that no one cares Help youth learn skills to strengthen their self-esteem and self-confidence Help youth to build trust and attachment through consistent contact Exposes youth to new experiences and places Offers opportunity to learn new skills or hobbies Assist them to feel safe and secure through a supportive and trusting relationship Encourages school, addresses independent living skills, continuing education, and employment avenues with youth (if age appropriate) Help youth learn positive techniques to cope with stress and develop and/or strengthen problem solving skills, decision making skills and improve behaviors Assists in setting goals, based on what the youth/ child s needs are Listens without judgment and expresses a positive outlook on life Be a positive role model Who qualifies for a mentor? Youth between the ages of 6-17 who have involvement with the Juvenile Justice System or Child Welfare System through Outagamie County Human Services. Youth who are at risk of or already placed outside of their home due to behavioral problems, family problems, abuse or neglect. Youth who are willing to participate and want a mentor. Who can be a mentor? Any mature adult who is willing to invest at least one contact with a youth per week (usually consisting of two to three hours). Each mentor is expected to make a 6-month commitment to the youth, must complete 10 hours of training, and clear a criminal record check, DMV check, and child welfare background check. Mentors also need 3 personal references and automobile insurance if they will be transporting youth. Questions? For more information or questions regarding the Mentoring Program contact Tammy McHugh (920) , or Nikki Gingras (920) Program Coordinators, at Outagamie County Youth and Family Services, 500 W. Fifth St., Appleton, WI or

3 QUALITIES OF SUCCESSFUL MENTORS Personal commitment to be involved with another person for an extended time generally, six months to one year at minimum. Mentors have a genuine desire to be part of other people s lives, to help them with tough decisions and to see them become the best they can be. They have to be invested in the mentoring relationship over the long haul to be there long enough to make a difference. Respect for individuals and for their abilities and their right to make their own choices in life. Mentors should not approach the mentee with the attitude that their own ways are better or that participants need to be rescued. Mentors who convey a sense of respect and equal dignity in the relationship win the trust of their mentees and the privilege of being advisors to them. Ability to listen and to accept different points of view. Most people can find someone who will give advice or express opinions. It s much harder to find someone who will suspend his or her own judgment and really listen. Mentors often help simply by listening, asking thoughtful questions and giving mentees an opportunity to explore their own thoughts with a minimum of interference. When people feel accepted, they are more likely to ask for and respond to good ideas. Ability to empathize with another person s struggles. Effective mentors can feel with people without feeling pity for them. Even without having had the same life experiences, they can empathize with their mentee s feelings and personal problems. Ability to see solutions and opportunities as well as barriers. Effective mentors balance a realistic respect for the real and serious problems faced by their mentees with optimism about finding equally realistic solutions. They are able to make sense of a seeming jumble of issues and point out sensible alternatives. Flexibility and openness. Effective mentors recognize that relationships take time to develop and that communication is a two-way street. They are willing to take time to get to know their mentees, to learn new things that are important to their mentees (music, styles, philosophies, etc.), and even to be changed by their relationship. Courtesy of MENTOR/National Mentoring Partnership.

4 500 W. Fifth St. Appleton WI MENTOR APPLICATION Thank you for your interest in becoming a mentor. The Outagamie County Mentoring Program provides a shared opportunity for learning and growth. In fact, many mentors say they are surprised and grateful for the experience, because it is more rewarding than they imagined. We look forward to working with you and introducing you to your mentee. Last Name First Name MI DOB / / Gender M F Marital Status Address City State Zip *I will be living in the area for at least 6 months Yes No Phone Alt Phone Race African American Native American Hispanic/Latino Asian Caucasian Other Please enter your children s information below: NAME D.O.B. Gender Residing with you Male Yes Female No Male Yes Female No Male Yes Female No Please list the name(s) of other members of your household and their relation to you: Name Relation Name Relation Name Relation Employment Information

5 Employer Position Address Length at Position Hours of Work Work phone Work May we contact you here? yes no List any experiences working or volunteering with youth: Agency/Program Date Phone/ May we contact the above agencies? yes no Education High School Received Diploma yes no College or Technical school _ Year Graduated Degree earned Post-Graduate school Degree earned Vehicle Information Do you hold a valid WI Drivers License? yes no *PROVIDE A COPY OF YOUR PROOF OF INSURANCE CARD WITH THIS APPLICATION* Please complete the questions below: What motivated you to inquire specifically about our mentoring program? Why do you want to mentor a child/teen in our program? Do you have any physical, mental or medical conditions, which might affect the type of contacts or the frequency with a youth? Please list three references we may contact (limit to ONE relative)

6 1. NAME ADDRESS Street, City, State, Zip code PHONE # ADDRESS In completing this questionnaire, I understand there is no commitment to the agency that a youth will be matched with me. I also understand that the agency is free to consult persons or agencies named herein. I hereby grant my permission to Outagamie County Department of Health and Human Services or their designee, to obtain references, criminal records, DMV records, child welfare records and any other records necessary to process my volunteer application. I understand that the falsification of any information in this application constitutes grounds for rejection or termination from this department s volunteer programs. Signature Date Please Return To: The Outagamie County Mentoring Program 500 W. Fifth St. Appleton WI hhsmentors@outagamie.org Fax: *PLEASE MAKE SURE YOU HAVE INCLUDED: Completed application including the Records Check form Wisconsin Background Information Disclosure form (separate document) Copy of proof of automobile insurance card For Office Use: Recheck Date: Hearing Date/Date Needed: Client/ Family Name: Worker For Office Use: References Received: Background Checks/DMV : Auto Ins Verified: Interview Date: / /

7 For Office Use: Recheck Date: Hearing Date/Date Needed: Client/Family Name: Worker 401 S. ELM STREET, APPLETON, WI TELEPHONE (920) FAX (920) RECORDS CHECK For the following: Law Enforcement Agency Criminal Background check State Department of Child Services County Departments of Human/Social Services agency records check Wisconsin Department of Motor Vehicle (Driver s Record check) State of Wisconsin Sexual Offender Registry Wisconsin Circuit Court Access Wisconsin Criminal History Check Credit Check (for proposed guardians only) Out of County/State CPS Records (not required for proposed guardian checks) I agree to have the Outagamie County Department of Health & Human Services investigate my past record and character. I hereby authorize the agencies listed above and law enforcement agencies for the jurisdictions where I have resided during the past FIVE years to check records and information available to them and to provide or verify such information on this form. Additionally, I hereby release said agencies, the Outagamie County Department of Health and Human Services, and all employees, officials, agencies, and any other representatives of these parties and all persons whomsoever from any claims, causes of action, damages, injuries, or losses I, my heirs, successors, or assigns may suffer or incur caused by the release of any information furnished as a result of this authorization and release. PLEASE CHECK ONE: Foster Care Foster Care Relicense Respite Kinship Care Volunteer Mentoring Guardian/Person Guardian/Estate Other NAME: (First) (Middle) (Last) (Other Names) (Maiden Name) DATE OF BIRTH: SOCIAL SECURITY NUMBER: Male: DRIVER S LICENSE NUMBER: Female: List all addresses where you have lived during the last five (5) years. Please attach a separate piece of paper if more space is needed. Begin with your CURRENT address. STREET ADDRESS CITY STATE ZIP COUNTY DATES (from/to) PLEASE COMPLETE BOTH SIDES OF THIS FORM INCLUDING SIGNATURE AND DATE OVER

8 List all charges and/or convictions (traffic, civil, criminal, etc.) Also include Probation/Parole and Court Supervision information. Please attach a separate piece of paper if more space is needed. TYPE OF OFFENSE LOCATION (CITY/STATE) DATE SIGNATURE: DATE: COMMENTS: For Office Use: *TO BE COMPLETED BY LAW ENFORCEMENT/CPS AGENCY* According to our records, this person does does not have records with our agency. (If so, please attach documentation.) Law Enforcement or CPS Representative Signature Date Municipality/Agency OUTAGAMIE COUNTY DEPT OF HEALTH & HUMAN SERVICES AGENCY RECORDS CHECK If applicable, date of last background check: Re-License: Yes No SEXUAL OFFENDER REGISTRY RESULTS: S:\HHS\HHSSHARE\Background Checks\FORMS\Records Check Form.doc Updated 2/10/2015