Skip to content
Toggle Navigation
Go to...
Tutorials
Mentor Application
Mentor Application
andrew.paulsen
2022-09-29T09:16:52-05:00
Mentor Name
(Required)
First
Middle
Last
A middle name must be entered. If the mentor does not have a middle name, please enter NA
Mentor Date of Birth
(Required)
MM slash DD slash YYYY
Mentor Age
(Required)
Mentor Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Mentor Email
(Required)
Mentor Home Phone
Mentor Cell Phone
Mentor Work Phone
Mentor Drivers License
(Required)
Address
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Mentor Sex
(Required)
Male
Female
Mentor Marital Status
(Required)
Single
Married
Divorced
Widowed
Separated
Mentor Ethnicity - Hispanic/Latino
(Required)
Yes
No
Race
(Required)
American Indian
Asian
Black
Native Hawaiian
White
Mentee Name
First
Middle
Last
How do you know the Mentee?
Who asked you to be a Mentor?
Were you a previous Challenge Academy Mentor?
Yes
No
Name of the most recent Cadet
Class & Year
Why do you wish to become a volunteer mentor for the Challenge Academy? (be specific)
Describe your driving record, include and offenses other than speeding.
Will you have transportation to mentor activities at Ft. McCoy?
Yes
No
Education - Highest Level
Education - Degree
Education - Area of Study
Employer
Occupation
Length of Employment
Current voluntary commitments
What type of experience do you have working with youth/children?
Current health condition
Poor
Fair
Good
Excellent
Do you have any physical limitations or special concerns?
Explain you past use of alcohol or any other drugs
Explain your present use of alcohol or any other drugs
Have you ever been involved in, investigated for, arrested, and/or convicted of a crime?
Yes
No
Briefly explain, including dates
Authorization to Release Information
I agree to the authorization to release information
I hereby authorize the Challenge Academy, along with law enforcement departments, to conduct whatever background check on me that may be deemed appropriate. I understand that this information is necessary to assist in determining my qualifications and suitability for a mentor position that I am applying for.
I fully understand that the information collected may be of a sensitive, confidential, and privileged nature, and may reflect upon my suitability. I hereby release the Challenge Academy and its agents from damage that may result from the exchange of requested information between law enforcement departments and the Challenge Academy.
I further authorize the Challenge Academy to release information, as deemed necessary, for the purpose of developing longitudinal and statistical studies and reports.
The information provided in this application is true and accurate to the best of my knowledge.
Mentor Signature
Date
MM slash DD slash YYYY
Duties and Responsibilities
By checking here, I certify that I have read, agree to, and understand the material below
• Serves as a role model, friend and advocate to the Cadet.
• Reports to the assigned Counselor and/or Mentor Coordinator.
• Returns completed screening material promptly.
• Commits to consistent contact with a Cadet while he/she is participating in the Challenge Academy.
• Observes all program policies and guidelines for mentors.
• Attends mentor training to learn how to relate effectively to Cadets.
• Participates in scheduled trainings and activities such as On/Off-site, and PRAP Review.
• Agrees to being contacted on a monthly basis by the Challenge Academy’s assigned Counselor, for the purpose of
discussing the Cadet’s progress.
• Discusses violations of policies by the Cadet with the Counselor and/or Mentor Coordinator.
• Communicates monthly by mail, e-mail, or phone with their Cadet’s assigned Counselor. Promptly informs the Counselor
and/or Mentor Coordinator of problems or needs in the Cadet’s life or their relationship.
• Makes consistent contact with the Cadet by phone, mail, e-mail, or in person.
• Maintains a minimum of 4 units of contact with Cadet monthly, as required.
• Submits a monthly report to the Challenge Academy when scheduled during weeks 14-22 of the Residential phase and
months 1-12 of the Post-Residential Phase.
• Monitor the Cadet’s Post-Residential Action Plan. Discusses with the Cadet his/her progress in executing the plan.
• Reports any changes of the Plan to the Cadet’s Assigned Counselor.
• Refers the Cadet to community resources as needed and helps the Cadet obtain those resources.
• Completes a community service project in your home community with the Cadet once per quarter during the Post-
Residential phase of the program.
• Shares informal activities with his/her Cadet. The mentor and Cadet will jointly select and schedule the activities.
• Completes an Exit Interview by phone, mail, or e-mail at the completion of the 17-month program.
Mentor Signature
Date
MM slash DD slash YYYY
Liability Release
By checking this box, I certify that I have read, agree, and understand the material below.
I understand and agree that I will be the one actually spending time with my Cadet and that I must exercise care in supervising him/her while we are together. I also understand that I am not a Challenge Academy employee, agent, and that I am responsible for choosing and conducting all activities with my Cadet and that the Challenge Academy does not retain any power to control how these activities are conducted except to require these activities to be conducted in the State of Wisconsin.
I therefore agree that the Challenge Academy, the National Guard Bureau, the State of Wisconsin, the Wisconsin National Guard, and their respective officers, officials, agents and employees (Released Parties) will not be liable for, and I agree to indemnify and hold harmless the Released Parties from any and all liability, causes of action, and losses imposed on them in
any way relating to or arising out of this mentoring agreement, including, but not limited to, liability for personal injuries, whether the liability, cause of action, or loss is caused by my action or inaction or the actions of inactions of the Release Parties.
I further release the Released Parties from any and all liability, claims, demands, or causes of action, whatsoever, arising out of any damage, loss, or injury I might sustain while participating in any activities pursuant to this mentoring agreement, whether such damage, loss, or injury is caused by the actions or inactions of the Release Parties.
My signature below certifies that I have read, agree to and understand the material above.
Mentor Signature
Date
MM slash DD slash YYYY
Release of Personal Information
By checking this box I certify that I have read, agree to, and understand the material below.
I authorize the Wisconsin National Guard Challenge Academy (Academy) to release my name, address, and telephone numbers to an institution or individual, whether public or private, for the purpose of advocating, supporting, and
furthering the mission of the Academy.
I further authorize the Academy to release said information as deemed necessary for the purpose of forming a parent support group, parent association, membership on a foundation to benefit the Academy, letter writing campaigns and class
reunions. This release shall remain in effect until revoked in writing by the undersigned individual(s).
My signature below certifies that I have read, agree to and understand the material above.
Mentor Signature
Date
MM slash DD slash YYYY
Confidentiality Agreement
By checking this box I certify that I have read and understand the material below.
Confidentiality is the preservation of privileged information concerning the client, which is disclosed in a professional working relationship. Part of what you learn is necessary to provide services to the applicant or client; other information is shared within the development of a helping trusting relationship. Therefore, most information gained on an individual and
family is classified as confidential.
Before you begin your assignment as a mentor you should be aware of the laws and penalties of breaching confidentiality. Giving information to unauthorized personnel could be interpreted as not within the scope of your duties. In this case Challenge Academy could refuse to support you in the event of legal action. Violation of the Wisconsin Revised Statues regarding confidentiality of records is punishable upon conviction by imprisonment in county jail for not more than sixty (60) days, or fines of $1000, or both. My duties as a mentor are to abide by the laws and policies regarding the preservation of confidential information.
My signature below certifies that I have read and understand the material above.
Mentor Signature
Date
MM slash DD slash YYYY
This field is hidden when viewing the form
Student ID
This field is hidden when viewing the form
Application Unique ID
This field is hidden when viewing the form
Applicant Last, First
Page load link
Go to Top
