SLTW Mentor Application 2012-2013

7/31/2019 SLTW Mentor Application 2012-2013

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The SLCC Community Writing Center& the Salt Lake City Public Library

invite you to participate in an award-winning mentoring program for local teens.

SaltLakeTeens Write(September 2012 - May 2013)In Salt Lake Teens Write (SLTW), underserved teens are paired with

mentors who use writing in their daily lives and professions.

Together, they meet to explore how writing opens different pathways to

education and successful careers. Any underserved teen entering the

11th Grade this coming fall is eligible to participate in this program.

Mentoring teams will meet for 1-2 hours a week and will work

together to produce a portfolio of writing based on the teens interests.

They will also attend quarterly writing workshops with the other SLTW

mentoring teams.

At the end of the year, all of the mentoring teams will come together

to collaborate on an anthology publication and public reading to

celebrate the different texts they have created during the year.

Application deadline for mentors is July 30, 2012.

For more information on how to get involved withthis program, please contact the

SLCC Community Writing Center at 801-957-2192,

[email protected] ORwww.slcc.edu/cwc.
mailto:[email protected]:[email protected]://www.slcc.edu/cwc.http://www.slcc.edu/cwc.http://www.slcc.edu/cwc.http://www.slcc.edu/cwc.mailto:[email protected]:[email protected]


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Thank you for your interest in serving as a mentor for Salt Lake Teens Write! Mentors will be notified of theiracceptance into the program by mid-August. Training will take place at the end August 2012. The program kick-off,where you will meet your mentee, will be in mid-September 2012. Please return this Mentor Interest Profile andthe Publicity Release to the Community Writing Center by July 30, 2012. Thank you!

Date: ________________________________________________________________________________________

How did you hear about Salt Lake Teens Write? ______________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Were you referred to this program? Yes _____ No _____

If you were referred to this program, please list that persons name. _______________________________________

Personal Information

First Name: _______________________________________ Last Name: ___________________________________

Street Address: __________________________________________________________________ Apt#:_________

City: __________________________________________________________ State: _____ Zip: ________________

Home Phone (_____) ________________________________ Cell: (_____) _________________________________

Sex: Female _____ Male _____

Salt Lake Teens Write communicates with mentors primarily by e-mail. Please indicate the email/s that you useregularly below.

Preferred Email: ________________________________________________________________________________

Alternate Email: ________________________________________________________________________________

Criminal Background CheckBecause you will be working with teens under the age of 18, a criminal background check through Utahs Bureau ofCriminal Investigation (BCI) must be completed as part of the application process. There will be no cost to you for the

background check; however, we do need your permission before we can initiate this process. Please check and initialthe appropriate lines below to indicate your will ingness to allow us to perform a background check.

I give permission for a criminal background check to be performed:_____Yes _____No Initial: ___________

All background checks for Salt Lake Teens Write mentors will be carried out this summer. As soon as we contact BCI and

receive the required background check forms from them, we will email you with that information.

Salt Lake Teens Write 2012-2013 Mentor Interest ProfileSalt Lake City Library/ SLCC Community Writing Centerhttp://www.slcc.edu/cwc/ (801) 957-2192

Mentor Interest ProfileSalt Lake Teens Write

2012-2013
http://www.slcc.edu/cwc/http://www.slcc.edu/cwc/


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Professional Information

Company/Organization: _________________________________________________________________________

Occupation Title: _______________________________________________________________________________

Street Address: ___________________________________________________________________ Suite #:_______

City: __________________________________________________________ State: _____ Zip: ________________

How long have you been employed with current employer? ______________________________________________

Business Phone (_______) ______________________________________________ Extension: __________________

May we contact you at work? Yes _____ No _____

Education (please "X" all that apply)

____ HS Diploma ____Some college ____ AS/AA/AAS degree____BA/BS/BFA degree ____Some graduate school ____MA/MS/MFA degree____PhD/JD/EdD/MD ____ MBA ____Other education (certificate/diplomas)

Ethnic Background (please "X" all that apply)

_____ African/African-American/Black _____ Arabic/Middle Eastern_____ Asian _____ Native American/American Indian/Alaskan Native_____ Caucasian _____ Hispanic/Latino/Latina_____ Pacific Islander _____ Other

Language Use

Are you proficient in any language other than English? Yes _____ No _____

If yes, indicate which language(s): __________________________________________________________________

Writing Experience

What types of writing are you proficient in? (Check all that apply.)

____Academic ____Business writing ____Childrens Literature

____Criticism ____Editing ____Fiction

____Grantwriting ____Journalism ____Marketing/PR

____Medical ____Non-Fiction ____Poetry

____Proofreading ____Science writing ____Screenplay/Drama

____Songwriting ____Technical Writing ____Translation

____Web-based writing ____Other, Please list: ______________________________________________

How do you use writing in your daily life and/or profession?

Salt Lake Teens Write 2012-2013 Mentor Interest Profile

Salt Lake City Library/ SLCC Community Writing Centerhttp://www.slcc.edu/cwc/ (801) 957-2192


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ExperienceHave you volunteered for any other organizations? Yes _____ No _____

If yes, please describe:

Do you have any mentoring experience? Yes _____ No _____


Do you have any teaching experience? Yes _____ No _____


Do you have any business or design skills? Yes _____ No _____


(Optional) Please check any areas where you might be interested in donating your expertise:

_____Mentoring Management (helping support our mentor/mentee pairs)

_____Developing Curriculum & Writing Experiments

_____ Leading Writing Workshops (Indicate what type):

_____ Special Event Planning

_____ Publications/ Design

_____ Working with Diverse Populations (Please specify):

_____ Working with English Language Learners

_____ Working with People with Disabilities

_____ Working with People Facing Socio-Economic Barriers

_____Other, please describe: _____________________________________________________________________

MotivationWhat motivated you to want to join Salt Lake Teens Write?

What would you like to accomplish?

Salt Lake Teens Write 2012-2013 Mentor Interest ProfileSalt Lake City Library/ SLCC Community Writing Centerhttp://www.slcc.edu/cwc/ (801) 957-2192


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What qualities do you possess that would make you a good mentor?

What are some of the challenges you anticipate with becoming a mentor, and how might you address thesechallenges?

Are you willing to report, on a monthly basis, your experiences and hours spent mentoring?

New Ideas

Although the Salt Lake Teens Write program will provide extensive training and support to all mentors, you infuse theprogram with fresh energy and enthusiasm. Please describe what you can imagine creating for the following twosituations:

A one-hour mentoring session with a 16 year old who is interested in any type of writing.

A one-hour writing workshop exercise for a small or large group of teens and their mentors in the genre of yourchoice.

AvailabilityCan you meet the programs minimum standard of spending at least one hour per week with a teen, in addition toattending the quarterly Saturday workshops? Yes _____ No _____

Are you willing to travel out of your residential/work neighborhood to meet with a teen? Yes _____ No _____

Are you available to participate in Salt Lake Teens Write from September 2011 through June 2012?Yes _____ No _____

Do you have any physical accommodation needs you think we should be aware of? Yes _____ No _____





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ReferencesPlease provide us with at least one professional reference and one personal reference. These individuals should haveknown you for at least two years. Please do not use relatives.

Professional Reference

Full Name (Mr. Ms. Mrs. Dr./Title): __________________________________________________________________

Company/Organization: _________________________________________________________________________Address: ______________________________________________________________________Suite #: _________

City: _______________________________________________________ State _________ Zip ________________

Business Phone: (____) ____________________________ Home Phone: (____) ______________________________

Relationship to you: _____________________________________________________________________________

Personal Reference

Full Name (Mr. Ms. Mrs. Dr./Title): __________________________________________________________________

Company/Organization: _________________________________________________________________________

Address: ______________________________________________________________________Suite #: _________

City: _______________________________________________________ State _________ Zip ________________Business Phone: (___) _____________________________ Home Phone: (____) ______________________________

Relationship to you: _____________________________________________________________________________

Commitment Statement

I, ____________________________________________________, understand that Salt Lake Teens Write is avoluntary program that I am choosing to participate in. I understand the benefits I will see from being a mentor in thisprogram depend on my willingness and ability to participate fully in the activities (mentoring team, group writingworkshops, blog discussions, etc.). I am committed to doing the best that I can to fully participate in all aspects of thiswriting mentoring program.

I certify, by my signature below, that all of the information and statements in this Mentor Interest Profile are true tothe best of my knowledge.

_________________________________________________________ ____________________________

Signature Date

(Typing your name here in an electronic format indicates a legal signature.)

Thank you for your interest in Salt Lake Teens Write! If you are selected as a mentor for the 2012-2013 program,

you will be notified by email in August. If you do not have an email address, then you will be notified of youracceptance by phone. Mentor training will take place in late August 2012, and the Salt Lake Teens Write programwill officially begin in September 2012 at a kick-off celebration where you will be introduced to the teen you will bementoring.




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I, [Participant Name, please print] _______________________________________________________,understand that while I am involved in the Salt Lake Teens Write program there may be written materialspublished, photographs taken, voice recordings made, or other records made of my image or likeness,including the publication of my name, for the purpose of promoting or publicizing the program and/ordisseminating work prepared for the program. Some or all of these materials may be published on paper,on the Salt Lake City Public Library or SLCC Community Writing Center websites, or through other forms ofelectronic media.

I expressly permit my writing, image, likeness, and/or name to be used in connection with publicizing orpromoting the Salt Lake Teens Write mentoring program and/or disseminating any work prepared for theprogram.

I further understand that I shall be entitled to any compensation or anything of value in connection with theuse or dissemination of my writing, image, likeness, or name.

I release and discharge the Salt Lake City Public Library and the SLCC Community Writing Center fromany and all claims and demands arising out of or in connection with the use of my writing, image, likenessor name, including any and all claims of libel.

Please sign and return this form to the Community Writing Center by July 30, 2012. Thank you!

______________________________________________ _________________

Participant Signature Date

______________________________________________ _________________

Witness Signature Date

Publicity Release for MentorsSalt Lake Teens Write

2012-2013

Documents

SLTW Mentor Application 2012-2013