New Jersey GEAR UP

NJ GEAR UP Mentors

Mentoring Overview

•

Why Mentor?

•

Application

•

Q & A

Application

Download the Mentor Application or complete online below.
Mail hardcopy applications to:

Errol Bruce
GEAR UP State Coordinator
NJ Higher Education
P.O. Box 542
Trenton, NJ 08625-0542
Fax (609) 292-7225

Instructions for online application

Use the TAB key to move from field to field (SHIFT+TAB will move back).
The ENTER key (except within a multi-line box) will submit the form.
DO NOT PRESS ENTER UNTIL YOU HAVE COMPLETED ALL SECTIONS!

NOTE: All information will be transmitted via a Secure connection.

Part A: Personal Information
Name (first, middle initial, last):
Campus address:	-
Campus Phone:
Best Time to Contact You:
Email address*:	* Must be a valid Email Address!
Permanent Address:	-
Permanent Telephone:
Can You Be Reached at Home:	Yes No
Social Security Number:
Driver License Number:
Date of Birth:
Gender:	Male Female
Currently employed?	Yes No
If currently employed, How many Hours per Week:
If currently employed, Employer's Name & Address:	-

Part B: Academic Information
University or College:
Number of Credits Completed:
Cumulative G.P.A.:
Major:
Minor:
Year in College:
Have you participated in the EOF (Educational Opportunity Fund) program?	Yes No
If yes, at what institution?

Part C: Mentoring Preferences
City where you would be available to mentor	Trenton Jersey City Camden Newark Paterson
What month are you available to start?
Is your schedule flexible?	Yes No

Part D: Volunteer Experience

Have you ever been a mentor? Yes No

If yes, please describe your experience:
-

Have you had volunteer or work experience with youth? Yes No

If yes, please describe your experience:

What other volunteer experience have you had?

Part E: Interests and Special Skills

Are you involved in any extracurricular activities on your campus? Yes No

If yes, please describe:

What are your special skills? (e.g. computer, math, leadership):

What are your interests? (e.g. photography, music, hiking, theater, sports):

What are your career goals?

Part F: Your Reasons for Becoming a NJ GEAR UP Mentor

Why do you want to become a NJ Gear Up Mentor?

What do you think you can bring to the mentoring relationship?

Part G: Background

Have you ever had an alcohol or drug abuse problem? Yes No

If yes, please explain:

Have you ever been convicted of an offense other than a minor traffic violation? Yes No

If yes, please explain:

Part H: References List two references who have known you for more than one year who can provide a personal reference (e.g., teacher, college counselor, employer). Please do not list relatives.
1. Name:
Years known:
Address:
City:
State:
Zip:
Telephone:
Relationship to you:

2. Name:
Years known:
Address:
City:
State:
Zip:
Telephone:
Relationship to you:

As a NJ GEAR UP mentor, I understand and agree to the following conditions:

To undergo a criminal background check
To spend about five hours per week with NJ GEAR UP students
To make an initial six-month commitment
To work with NJ GEAR UP students under supervised conditions at all times
To work with NJ GEAR UP students during a probationary period until the criminal background check is completed
To understand that I can be dismissed if the criminal background check reveals a criminal offense that can adversely affect the program or NJ GEAR UP students
To ask for assistance when I need help with mentoring relationships
To work closely and cooperatively with NJ GEAR UP staff members during all phases of the program
To notify NJ GEAR UP staff members and NJ GEAR UP students when I am unable to keep my weekly commitments
To be on time for scheduled events
To attend training sessions
To maintain a good academic standing

I do hereby understand and agree to the above commitments and responsibilities and attest that all of the information I have provided on this application is correct to the best of my knowledge. I understand that entering my initials and clicking on the SUBMIT APPLICATION button below will be considered the equivalent of my legal signature.

Where did you hear about the NJ GEAR UP mentoring opportunity?:

Enter your initials to indicate acceptance of above conditions and the completeness and accuracy of all information submitted.

Thank you for your interest in becoming a NJ GEAR UP mentor. We appreciate your thoughtful attention to these questions, and we will schedule an interview with you if your application is accepted. Please contact Errol Bruce at Phone (609) 341-3807 with questions or problems with this form.