Dear Potential Mentor, Thank you for taking the time to fill out this questionnaire. The questionnaire is vital to helping us understand you and your possible placement as a Mentor in our program. If you are accepted as a Mentor a considerable amount of time, resources, and commitment will be put behind you and the youth you will mentor over the next four years. Because of this investment we want to honor our donors and research each potential mentor to the best of our ability. Your responses help us determine how best we can serve you and your youth. Feel free to be honest. We are not greatly concerned about your past because your past makes you who you are today and can help you relate well to your possible mentees who are growing up in tough situations. As long as our mentors can pass random drug tests throughout the year we are open to having mentors with very colorful pasts. Be assured that the information you provide below will be kept strictly confidential. Ready to go? Great, tell us all about yourself!
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Current School (if in school)
Previous Semester/Quarter GPA:
Current Cumulative GPA:
High School Cumulative GPA:
Did your father go to college?
Did your father finish college?
Did your mother go to college?
Did your mother finish college?
Did you grow up with your biological parents?
If 'no', did your guardians go to college?
Did your guardians finish college?
Was there an adult male figure at home?
Were either of your parents/guardians incarcerated?
Please rate your high school attendance on a scale of 1 to 5. 1 means you did not miss classes. 5 indicates you skipped class on a regular basis.
Please rate your gang involvement on a scale of 1 to 5. 1 indicates you have/had no contact with gangs. 5 indicates you were or are actively involved in a gang on a regular basis.
Tell us about your education after high school:
What are some of your interests outside of school?
Did you exhibit behavior problems in high school or middle school? If yes, please explain.
Did you exhibit behavior problems at home growing up? If yes, please explain.
Have you had any problems with the law? If yes, please explain.
How many times have you moved in the last five years?
When was the last time you moved and where did you move from?
Do you plan on moving in the next four years? Please explain your answer.
How open are you to being mentored?
Why do you feel you should be a Mentor for MUST?
What are your plans for college?
Do you own a car?
How long have you been driving?
How many accidents have you been in?
Please list a personal reference (friend) and include their name, phone number and how you know them.
Please list a professional reference (boss, coworker... etc.) and include their name, phone number and how you know them.
Please list a character reference (client, pastor, coach... etc.) and include their name, phone number and how you know them.
MUST understands that the following questions are very personal. If you do not feel comfortable answering them then please feel to leave them blank. The answers to these questions are helpful in matching you, the Mentor, to your potential Youth but are not necessary. We measured the prevalence of ten Adverse Childhood Experiences (ACE), consisting of whether the child ever experienced one of the following. Please answer the following regarding your childhood. 1. Did a parent or other adult in the household often or very often… swear at you, insult you, put you down, or humiliate you? or act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in the household often or very often… push, grab, slap, or throw something at you? or ever hit you so hard that they had marks or were injured?
3. Did an adult or person at least 5 years older than you ever… touch or fondle you or have them touch your body in a sexual way? or attempt or actually have sex with them?
4. Did you often or very often feel that … no one in your family loved you or thought you were important or special? or your family didn’t look out for each other, feel close to each other, or support each other?
5. Did you often or very often feel that … you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
6. Were your parents ever separated or divorced?
7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
10. Did a household member go to prison?
Thank you for filling out this application! Is there anything else you would like to communicate with us?
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