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South Carolina Youth ChalleNGe Academy

P.O. Box 2808West Columbia, SC 29171

Dear Prospective Mentor:

The youth

asking you to consider being a mentor prospect for him/her

actively

seeking admittance

to the YouthChalleNGe Academy. Our goal is to provide at-risk youth with values, skills and the education needed to succeed as productive citizens. The program, under the direction of the National Guard Bureau, begins with a

5 ½-monthResidential

Phase

, comprised of academic instruction and physical training. After which the youth returns to their homecommunities

to work with a mentor during the 12-month Post-Residential Phase

to maintain and build upon their lifestyle changes developed during the residential phase.

Before completing the application, please note if you meet the following qualifications:

You must:



Be at least 21 years old



Be the same sex as the young person



Live within a reasonable locality of the youth’s home address (no more than 25 miles)



Be a good role model



Complete, sign and return the entire application



Consent to undergo a background screening

You must not:



Live in the same residence of the young person



Be a relative of the young person (No parents, step-parents, or siblings)



Be a romantic interest of a relative of the youth, or relative of the youth’s romantic interest



Be a ChalleNGe staff person or spouse of a staff personIf you are qualified to initiate the application process as a prospective mentor, please do the following:

•

Review the Mentor Prospect Primary Responsibilities Sheet

•

Complete and Sign the Entire Application.

•

Complete and Sign the Mentor Authorization to Release Information Form.

This form grants the Academy permission to conduct a background screening process.

Note:

We cannot process your application without this form.

•

Provide Two (2) References

Give the two reference forms to two (2) people who know you well. Ask them to complete the referenceforms about you. You must ensure that these are returned with your application.

Please return your application to the address above or you may fax it to (please call for current number).

Thank you for your dedication to the youth of our state. If you have any other questions or concerns, please contactMrs. Martha Owens at (803) 832-4878.Sincerely,Roy SmithRecruitment, Placement and Mentoring Coordinator Mentoring Department

Mentor ProspectPrimary Responsibilities

The SC-Youth ChalleNGe Academy has

three phases

.The

first phase

is the

Pre-ChalleNGe

(Hard Core phase)

During this

two week

phase the “candidate” has zero privileges and endures a lot of physicalexercise and drill and ceremony.The

second phase

is the

Residential phase

.During the next

twenty weeks

, the cadet works toward completion of the GED diploma as well aslife and job skills, community service, physical fitness, leadership / followership, health education andresponsible citizenship. During this phase, the cadet’s approved primary mentor will need to bescreened, trained and matched prior to week 13.The third and final phase is the

Post-Residential

phase

, the cadet will return home.During these

twelve months

the “matched mentor” and the mentee meet four times monthly.Two contacts are to be face-to-face and two may be either by phone, email, letter, etc…The

“matched mentor’s” primary job is

to be a friend to the cadet/mentee and to help in whatever way he or she can to keep the cadet/mentee focused on his or her goals. The mentee’s goals will beoutlined in a Post-Residential Action Plan (P-RAP). A copy will be mailed to the “matched mentor”prior to graduation and one copy will be given to the cadet at graduation.The “

Primary Mentor Prospect’s” basic responsibilities are

as follows:

•

Complete and submit an application and to an application process.

•

Attend a “one-time” “one-day” training session.(This session is usually scheduled on a Saturday here at the academy.)The

“Matched Mentor’s” basic responsibilities are

as follows:

•

During the Residential Phase - Participate in the “letter writing campaign”.This begins around week 14 and occurs bi-weekly.

•

During the Post-Residential phase - Meet with mentee four times monthly(2 face to face contacts, other contacts may be telephone, letter, e-mail, etc…).

•

During the Post-Residential Phase - Complete and return a monthly reportverifying the mentee’s current placement and your contacts with the mentee.Your assigned case manager will mail this report to you each month.

STAFF USE ONLY: (W)

Primary Mentor Prospect 1Alternate Mentor Prospect 2

South Carolina Youth ChalleNGe Academy

Prospective Mentor Application

Please print.

YOUTH’S NAME: _______________________________________________________ Prospective

Mentor’s

Last Name:

_______________________________

First Name

: ____________________

: _____

Do you live in the youth’s household? Yes / No Indicate number of miles from youth’s residence: *________ *

Note: You may live no more than 25 miles from the student’s home address.

Statistical Data

Gender:

(Circle One) Male / Female

Ethnicity:

(Circle One): Black Hispanic White American Indian Asian Other

Marital Status:

(Circle One) Single Married Divorced Widowed Widower

Date of Birth

: Month _______________Day ________ Year ___________ Age __________

SSN#

_________/________/______________ (Required For Screening Purposes In Cases Of Duplicate Names and/or DOB)Spouse’s Name: __________________________________________________ Age: __________ Number of Children: _______

Driver’s License State

: _______

Number

: __________________________ Do you have your own transportation? Yes / NoIf you do not, do you have access to transportation? Yes / No Please Describe: ______________________________________ Vehicle Insurance Company: _______________________________ PolicyNo: _______________________________________

Employment Information

Occupation

: _______________________________________________

Employer

: ____________________________________ Length of Employment: _____________ Status: (Circle One) Full / Part Time / Volunteer / Unemployed / RetiredList other employment you have

held during the past five (5) years

, beginning with the most recent job, first:OccupationEmployer Length of Employment Reason for Leaving ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Personal Contact Information

Home Phone

: (_____)__________________

Work Phone

: (_____)_________________

May we call you at work?

Yes / No

E-Mail: _________________________________________________________ Cell

Phone

: (____)_______________________

Mailing Address

: ______________________________________________________________

Lot / Apt #

_______________

City:

___________________________________________

State:

_______

Zip

: _____________

County

: __________________ List

other residences

during the past five (5) years

, beginning with the

most recent

place, first. Continue on back if needed:AddressCity/State Length of Stay ____________________________________________________________________________ Years ______ Months ________ ____________________________________________________________________________ Years ______ Months ________ 1