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What is EmpowerGirls?

The EmpowerGirls Youth Mentoring and Leadership Development Program is a school-based model serving girls between the ages of 11–17 in targeted public and charter schools. Our vision is to Empower young girls through Mentoring, Prevention, Opportunities, Education, and leadership while providing access to Resources that foster self-realization, academic excellence, and optimal health and wellbeing. Program participants are exposed to educational workshops, STEAM programs, community service projects, mentoring, and support services in order to develop a commitment to academic success, foster essential life skills, develop an understanding of healthy and respectful relationships, and increase their awareness of social issues while building their self-esteem.

Our areas of focus include:

Cultural Awareness Science, Technology, Engineering, Arts & Math (STEAM) Health and Well-Being Civic Engagement and Leadership Development Diversity and Racial Justice Empowerment College Readiness and Career Development

Want to make a difference? Become a mentor today!

Agree to make a one (1) year commitment as a mentor. Spend a minimum of eight (8) hours per month one on one with a mentee. Mentoring sessions can take place one-on-one, at a location in the community, as well as during

structured activities organized by the YWCA. Mentors are encouraged to attend all EmpowerGirls monthly group sessions as well as interact with

their mentees on a weekly basis to build and maintain meaningful relationships. Mentors participate in an interview, complete criminal background check and child abuse

clearances, and attend an orientation to get started. YWCA offers two mandatory in-service trainings to support your relationship with your mentee.

This is your chance to invest in the life of a young girl while developing marketable leadership skills. As a mentor, you can make a difference in the lives of DC Metro Area youth! Join TODAY!

If this is an opportunity that you are interested in, please complete the form below and e-mail it to [email protected].

1YWCA National Capital Area | 2303 14th St. NW, Ste. 100 | Washington, DC 20009 | P 202.626.0700 | F 202.347.7381 | www.ywcanca.org

2019 - 2020 EmpowerGirlsMentor Application Form

PERSONAL INFORMATION

Name: ______________________________________________________________________________

Date of Birth: ____/____/____ E-Mail: __________________________________________________

Home Address: _______________________________________________________________________Street City State Zip Code

Ward (circle one): 1 2 3 4 5 6 7 8 Other: ____________

Phone Number: (Cell) ____________________________ (Work) _____________________________

Emergency Contact Name: ______________________________________________________________

Emergency Phone Number: _____________________________________________________________

DEMOGRAPHICS

EthnicityNo, not Hispanic/Latino Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto

Rican, South or Central American, or Spanish culture or origin regardless of race

Race (Check all that apply)

AsianHispanic or Latino

Black or African AmericanWhite

American Indian or Alaskan NativeNative Hawaiian or Other Pacific Islander

Family Information: Income

≤ $9,999$30,000-$39,000$60,000 – $69,999

$10,000 - $19,999$40,000-$49,999$70,000-$79,999

$20,000 - $29,999$50,000 - $59,999≥$80,000

Size of Household: Number of people living in home

1-26

37

48

5≥9

HEALTH INFORMATIONDo you have any health conditions or restrictions you think we should be aware of (physical, psychological, allergens, etc.?)* _______ Yes ______No

If yes, please describe: _________________________________________________________________


WORK HISTORY

Current Employer: ________________________________ Occupation: __________________________

Circle your level of educational attainment: High School Some College Bachelor’s Masters PhD

College/University Attended/Attending: ______________________________ Graduation Year_______

Major/Minor: ________________________________________________________________________

Are you involved in any other social or civic activities (sororities, volunteer groups, etc)? Yes No

If yes, please list: ______________________________________________________________________

Do you speak any language in addition to English? Yes No

If yes, please list: ______________________________________________________________________

Do you have any previous experience mentoring/volunteering with youth? Yes No

If yes, please explain: __________________________________________________________________

And, for how long (months, years)?_______________________________________________________

Have you ever been arrested or convicted of a crime? Yes No

If yes, please explain: __________________________________________________________________

TRANSPORTATION INFORMATION

Do you have a valid driver’s license? Yes No

Do you currently have a vehicle? Yes No

Is your vehicle currently insured? Yes No

MATCHING INFORMATION

Please rank the following age groups you would like to work with 1-3 (1 being most interested; 3 being

the least interested):

______ Middle School (10 – 13) ______ High School ______No Preference

Please note briefly why you have chosen to mentor with the EmpowerGirls Mentoring Program.____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Please list any hobbies or special skills: ____________________________________________________

Please list any sports you have played: ____________________________________________________


Would you be interested in leading or coordinating an interactive presentation on one of the following subjects? (Check all that apply)

o Healthy Relationshipso STEAM Activities & Career Explorationo Financial Literacyo Anti-Bullying

o Health & Nutritiono College Readinesso Racial Justice & Diversityo Etiquette Training

Are you interested in serving on the Young Women’s Leadership Council? ______YES ______NO

How did you hear about the EmpowerGirls Youth Mentoring and Leadership Development Program?Friend/FamilyOther Agency:___________Special event

Employer/SchoolChurchOther:_________________

LibraryPoster/ad

REFERENCESPersonalName___________________________________________________Phone___________________________

Years known___________

ProfessionalName___________________________________________________ Phone___________________________

Years known ___________Informed Consent - Please read carefully before signing.

I agree to make a one (1) year commitment as a mentor. I understand that the mentoring program involves attending a monthly weekend group event

and/or program sessions with mentees for the EmpowerGirls academic year from October 2020 - May 2021.

I understand that I am required to complete criminal background check and submit health screening information to participate in the program.

I understand that I am required to attend an orientation, mixer, and two mandatory trainings. I agree to follow all mentoring program guidelines and understand that any violation will result in

suspension and/or termination of the mentoring relationship.

I hereby certify that I have never been involved in any criminal activity, felony or misdemeanor. I further certify that all information provided on this application is true and complete. I understand that falsification or significant omissions of any information may be considered justification for non-acceptance or dismissal if discovered at a later date. I certify that the facts contained in this application are true and complete to the best of my knowledge.

Signature: ___________________________________________________ Date: ____________________


Thank you for your interest in the EmpowerGirls Youth Mentoring & Leadership Development Program. We appreciate your thoughtful attention to these questions.

Final application checklist:____ Completed application

____ Mentor Contract

____ Mentor Matching Questionnaire

____ Criminal Background Check

____ Health Clearance

____ HIPAA Form

____ Photo Release Form

____ Optional: Other Attachments (recommendations, resume’, writing sample, etc.)

Please mail, fax, or email your completed application and attachments/forms to:YWCA NCA National Capital Area - EmpowerGirls2303 14th St., NW, Suite 100Washington, DC 20009T: 202-626-0704F: [email protected]

Next Steps: If your application is accepted, we will email you to schedule an interview. Upon successful completion of the interview and background check, you will be invited to the

Mandatory Mentor Orientation.

FOR OFFICE USE ONLY

Application Received

Mentor Contract

Mentor Matching

Questionnaire

Health Clearanc

eHIPAA Photo

ReleaseOptional

Forms

Entered in

Database

InterviewComplet

e

Background Check

Complete

Attended Orientation


Mentor Contract

As a member of EmpowerGirls, I understand that:

1. I agree to be matched with a female mentee between the ages of 10-17 years.

2. I agree to make a one (1) year commitment as a mentor. Mentor/Mentees are expected to interact for a minimum of 8 hours per month.

3. Mentoring sessions can take place one-on-one, at a location in the community as well as during structured activities organized by the project.

4. I will show respect, concern, goodwill and consideration toward everyone involved in the EmpowerGirls program - everyone is responsible for assuring that no one feels “left out.”

5. I agree to participate in structured group activities.

6. I will not use my cell phone while program activities/sessions between the mentor/mentee are taking place.

7. I am required to attend two mandatory trainings.

8. I will be responsible for providing YWCA with regular updates on the relationship with my assigned mentee.

9. I am required to bring to the YWCA attention matters that may put the mentee in danger.

10. I have the right to ask for a change or to terminate the relationship with my assigned mentee and/or YWCA National Capital Area.

11. I understand that continued interaction between the students after the conclusion of the YWCA arranged match will be a separate agreement between me, the mentee and her family.

12. I will notify staff, for any reason, if my commitment to the EmpowerGirls program ends prior to completion of the academic year.

__________________________________ ________________Mentor Signature Date

_____________________________________ ________________Manager, Youth Programs Signature Date

Mentor Matching Questionnaire 6

YWCA National Capital Area | 2303 14th St. NW, Ste. 100 | Washington, DC 20009 | P 202.626.0700 | F 202.347.7381 | www.ywcanca.org

2019-2020

Name: Ward /County:

Highest degree attained: Current employer:

Major/Discipline: Job title:

School:

Do you speak any languages other than English? (Circle one) Y N

If yes, which language? How well? (Circle one)Still learning Well Very well

Availability outside of the program to contact your menteePlease indicate for each day:AM/Midday/Afterschool/Evening

M T W Th F Sat Sun

Communication Preference please rate 1-5 (1 being the best, 5 being worst)

Email Phone call Text message

In-person Other:

Which of these activities are you most likely to regularly participate in? Please circle the top 5.Chemistry/

Math/PhysicsJogging/

Running/Biking Crafts Shopping Games/Puzzles

Photography Playing Sports Drawing/Coloring Listening to Music Playing Video Games

Computers Dance Writing Playing Musical Instrument Cars/Trucks

Nature/Animals Biking/Skateboarding Cooking Learning Other

Cultures/History Watching Movies/TV

Gardening Hiking Reading Fashion/Fashion Design Watching Sports

What adjectives do people use to describe you? Ex. happy, ambitious, quiet, helpful, outgoing, reserved, etc.

When you were in school, can you describe what you most enjoyed doing and studying? What were your career aspirations?

If you were watching a group of youth in a classroom, circle which children you would most likely gravitate towards? Draw a line through the group of children it would be harder for you to work with.


Funny Energetic Studious Sarcastic Argumentative

Quiet Happy Mischievous Serious Talkative

Cooperative Withdrawn Questioning Curious Obedient

What kind of relationship are you hoping to experience as a mentor in our program? Please explain your goals and motivations for participating as a mentor in the EmpowerGirls program.□ Casual – We contact each other when we want to talk, knowing that the other person will be available for support when needed. □ Formal – We schedule meeting times, phone calls, or e-mails to update each other on life events and keep in contact.□ Other – Describe:

If your mentee needs help for class/project, what subject (s) are your MOST comfortable tutoring with?

Is there anything else you think we should know about you that will help us in making a good match?

Do you already have a match preference? Please provide name of student.

BACKGROUND & HEALTH CLEARANCE PROCESS:8

YWCA National Capital Area | 2303 14th St. NW, Ste. 100 | Washington, DC 20009 | P 202.626.0700 | F 202.347.7381 | www.ywcanca.org

Please follow the 2 steps below to complete the background and health clearance process:

STEP 1 – FEDERAL BACKGROUND CHECK –

Once you have provided us with your completed application and an email address, you will receive an email notification from an organization called Intellicorp. Please respond to the email and fill out the necessary information online within 24 hours. Be sure to check your spam folder. After this is complete, the YWCA should receive your results in a few days. If you are interested in donating to cover the costs associated with your background check, please bring in cash or a money order in the amount of $28, written out to the YWCA National Capital Area. We appreciate your support!

STEP 2 – MENTOR HEALTH CLEARANCE & TB TEST – If you are new to the program or did not submit this information to us in the spring, please make an appointment with your healthcare provider to complete an annual physical and TB test. Please provide us with a copy of your health form that shows proof of immunity to vaccine-preventable diseases and tuberculosis screening. If you are a college student, your school’s Student Health Center should have your health immunization documentation on file; please ask for a copy.

Please call or email if you have questions or concerns.

AUTHORIZATION FOR RELEASE OF HEALTH CARE RECORDS AND INFORMATION TO YWCA OF THE

NATIONAL CAPITAL AREA

Name: _____________________________________________ Last four digits SS#: _______________


I hereby authorize: ___________________________________________(the “Practice”) to release a

copy of my Protected Health Information as described below to: YWCA of the National Capital Area

(“YWCA”), 2303 Fourteenth Street, NW, Suite 100 Washington, DC 20009.

Description of Protected Health Information to be released or disclosed: All Medical Records, Mental

Health Records (except any psychotherapy notes), and Medication Records

IMPORTANT: I understand that unless I specifically request that such information not be disclosed, authorized disclosures may contain Protected Health Information containing diagnosis, treatment and other information regarding psychiatric and mental health treatment, substance abuse treatment, genetic information, and HIV and/or AIDS.

Please DO NOT RELEASE any of the following Protected Health Information from my medical record:________________________________________________________________________

The Protected Health Information indicated above is to be used and/or disclosed for the following purpose(s):

For the YWCA to assess my educational needs and promote my progress in a YWCA educational program Other:

This authorization will remain in effect for a period of one year, from ____/_____/_____ to

____/_____/______. I understand that I may revoke this authorization at any time by notifying the

Practice in writing, but that any such revocation will not have any effect on any actions that the

Practice took before receiving my written revocation.

I understand that if the Authorized Recipient named above is not subject to the federal privacy

protection regulations, my Protected Health Information may be subject to further disclosure by the

Authorized Recipient and the information will no longer be protected under the federal privacy

protection regulations issued by the U.S. Department of Health and Human Services.

I understand that I may refuse to sign this authorization and that doing so will not interfere with my

treatment at or by the Practice or payment for that treatment.

I have read the above and authorize the use or disclosure of the Protected Health Information as

stated.

_______ ______


Signature of Patient or Patient’s Representative Date

If signed by Patient’s Representative, indicate relationship to the Patient:

Telephone Number Where Patient/Representative May Be Contacted:

YWCA of the National Capital Area2303 14th Street, NW Suite 100

Washington, DC 20009202-626-0700

Fax: 202-347-7381www.ywcanca.org



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Ethnicity · Web viewRace (Check all that apply) Asian Hispanic or Latino Black or African American White American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander