Application for quality-Based membership (2012) Program Name

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Application FOR Quality-Based MEMBERSHIP (2012)

Program Name ___________________________________________________________________
The above-named program submits this application to Mass Mentoring Partnership for membership. A member of MMP staff will contact you upon submission of the completed application.
Please check level of membership requested:

___Affiliate Member

An Affiliate Member is non-profit youth serving organization, mentoring program, service organization, faith-based organization, educational institution, cultural institution, institution of higher education, foundation, or other non-profit entity with a demonstrated commitment to youth mentoring as a direct service provider. An Affiliate Member program may access many benefits through Mass Mentoring Partnership, as described on the Membership Benefits chart, and may apply to become an Associate Partner Member at any time by meeting the minimum requirements. If you are applying to become an Affiliate Member, please skip any questions that are not applicable to your program.

___Associate Partner Member

An Associate Partner Member is a formal youth mentoring program or organization in operation for a minimum of twelve (12) months with adult to youth matches that have met for one cycle of the program’s designated minimum match duration. Associate Partner Members are either actively engaged in completing the program standards’ self-assessment or “On the Road to Membership” completing a work plan. Associate Partner Members may access many benefits through Mass Mentoring Partnership, as described on the Membership Benefits chart. Associate Partner Members must complete the self-assessment and the “On the Road to Membership” process within four months or return to the Affiliate Member level.

Partner Members of Mass Mentoring Partnership are formal youth mentoring programs or organizations that successfully completes the requirements of the program standards’ self- assessment and review process at the Associate Partner level.
Partner Members agree to (1) fulfill the obligations outlined in the Mass Mentoring Partnership Membership Agreement and (b) complete a biennial membership update.


Parent Organization (if applicable):_____________________________________________________

Year Founded: ___________ Federal ID # for 501C3 Status: ___________________
Street Address: _____________________________________________________________________

City/State/Zip Code: _________________________________________________________________

Organization Main Phone: ______________________ Web site: _________________________________

Executive Director: __________________________________________________________________

E-mail: ____________________________________ Phone: _______________________________
Mentoring Program Name: ____________________________________________________________
Year Founded: _________ Web site (if different from Parent Organization): _________________

Mentoring Program Manager: ___________________________ Title: ______________________

Phone: E-mail: _________________________ Fax: __________________
Street Address: ____________________________________________________________________
City/State/Zip Code: _________________________________________________________________

Name and Title of Individual to whom MMP will send volunteer referrals:

Year of first contact with MMP: ___________ # of Staff Positions _______ (full time equivalents)
How did the organization/program hear about Mass Mentoring Partnership: (Please check all that apply)
_______ MMP Website _______ Direct e-mail
_______ Referral from other organization _______ Direct mail
_______ Referral from funder _______ Other
_______ Event If other, please specify: __________________
Program is an Ambassador of Mentoring host site Yes____ No____
Please describe your mentoring program below or attach a document that describes your program.

Program description:




Program description, including primary goals of the program:




Match Model

____ 1 to 1 (one adult to one young person)

____ Group (one adult to no more than four young people)

____ Team (a group of adults matched with a group of young people)

____ Cross-Age Peer Mentoring (older youth matched with younger youth)
Location where matches meet:

In the community, matches primarily meet on their own

School-based program, matches meet during school hours or after-school only

School-based program, not associated with the mentee’s school

After school program, not associated with the mentee’s school

Faith-based institution, matches may meet at the site or in the community

Residential facility program, matches meet at the residence or in the community

Community-based organization, but the matches primarily meet at the organization and not in the community on their own

Workplace, matches meet primarily at the mentor’s workplace, may leave the site on occasion

On-line mentoring program, matches meet primarily online but may meet in person on occasion

Service Area

____ Greater Boston ____ South Coast, Cape, and Islands

____ Central MA ____ North Shore and Merrimack Valley

____ Western MA


____Barnstable ____Berkshire ____Bristol

____Dukes ____Essex ____Franklin

____Hampden ____Hampshire ____Middlesex

____Nantucket ____Norfolk ____Plymouth

____Suffolk ____Worcester

Recruitment Procedures

  1. Please list the groups that you primarily recruit. ___Men ___Women ___Both

___College students ___Young professionals ___Retired Persons ___High School Students

___Corporations/business partnerships ___Your organization or program staff

Other___ Please specify _____________________________________________________________

  1. When do you conduct your recruitment? When is your busiest recruitment time?

___Year round ___Spring ___Summer ___Fall ____Winter Busiest time is: ____________
Screening Procedures

  1. Do potential mentors complete a written application? ___Yes ___No

  2. Do you require a personal interview with potential mentors? ___Yes ___No

  3. Do you conduct a CORI check for potential mentors? ___Yes ___No

  4. Do you require at least two references from non-family members for potential mentors?

___Yes ___No

  1. Do you require potential mentors to attend a pre-match training? ___Yes ___No

  2. Do you have any additional procedures for screening potential mentors? If yes, please list


Match Information

1. In the last 12 full months, how many youth mentees were in mentoring relationships in your program: _____

2. As of today, how many youth mentees are in mentoring relationships in your program: _____

3. The mentor-to-youth ratio: ______ mentor(s) to ______ youth

4. Do you currently have a waiting list for your program? ____Yes ____No

If yes, how many are currently on the waiting list:

____ Mentees waiting for mentors ____ Males ____ Females

____ Mentors waiting for mentees ____ Males ____ Females

Mentee racial demographics for youth on waiting list: (please provide a numeric answer)

____African American ____Asian ____Latino(a) ____White, not Hispanic ____Other

Provide the number of youth on the waiting list for the following age groups

____Ages 6-9 ____Ages10-14 ____Ages15-19 ____Ages20-24

Mentor Information

1. Minimum age of mentor: ____

2. Mentor volunteer time commitment:
      Hours Per week       Hours Per month       Minimum duration (for example, 9 months, 1 year)

3. Mentor description: Please describe the characteristics of desired mentors for your program.



4. Desired gender of mentors: ____ Male ____ Female ____ Either

5. Accepting volunteer referrals: ____ Yes ____ No

6. Current Mentors Information:

Active number of mentors:

____Male ____Female

Mentor racial demographics:

____African American ____Asian ____Latino(a) ____White, not Hispanic ____Other

Enter the number of mentors in your program BY AGE:

____Ages 14-17 ____Ages18-22 ____Ages 23-35 ____Ages36-49

____Ages 50-64 ____Ages 65+

  1. Are mentors salaried employees of your program? ____Yes ____No

  2. Current Mentors include (check all that apply)

______High School Students ______College Students ______Retired Persons

______Affinity Groups ______Corporate Partners ______Other

Mentee Information

1. Mentee age range:      

2. Mentee grade level range:      
3. Gender of youth served:  Male  Female  Either

  1. Racial Demographics:

____African American ____Asian ____Latino(a) ____White, not Hispanic ____Other

5. Population served: Please describe your target population (i.e. age, ethnicity, gender, school attended, foster care youth, youth from a particular religious group, pregnant or parenting youth, etc.).


6. Mentee eligibility requirements: Please describe any special qualities or characteristics of the youth served by your program.



Program Budget
What is the annual budget of your mentoring program based on your last fiscal year? (If your program is a component of a larger organization, provide annual budget for just your mentoring program rather than your organization as a whole.) The annual budget should include (1) expenses for payroll, administration, occupancy, materials, travel, events, etc.  Do not include the value of time donated by mentors; and (2) in kind benefits, such as DONATED marketing, legal services, advertising space and match activities.
____Less than $50,000 ____$50,000 to less than $100,000

____$100,000 to less than $250,000 ____$250,000 to less than $500,000

____$500,000 to less than $750,000 ____$750,000 to less than $1 million

____More than $1 million

_____________________________________ ­­­­­­­­­­­­­­­­­­­­­­_________________________

Signature - Mentoring Program Manager Date

_____________________________________ _________________________

Signature - Executive Director of Agency Date

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