Bodwell Center for Service and Volunteerism

Black Bear Mentors Application

Thank you for your interest in becoming a Black Bear Mentor. The Black Bear Mentors Program began in 2003 and has served over 300 youth and over 400 college students in the last 16 years. In 2010 Black Bear Mentors and Big Brothers Big Sisters of Mid-Maine established a partnership  to expand BBBSMM programming to youth in grades K-8 in Penobscot County. Black Bear Mentors works in collaboration with Big Brothers Big Sisters to support each mentoring relationship.

 

Black Bear Mentor Application

• Personal Information

• Legal Name*
  First Last
• Preferred Name
• UMaine Student ID# (Please include leading 0)*
• Please write your pronouns here:
• Address*
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Date of Birth*
  Month

  Day

  Year
• Are you a US Citizen?
  • Yes
  • No
• Ethnicity (Optional)
• Phone*
• Preferred Email Address*
  Enter Email Confirm Email
  Please enter an email address that you check regularly.
• Preferred Method of Contact (Please check all that apply)*
  • Text Alerts
  • Email Alerts
• Year in School*
  • First
  • Second
  • Third
  • Fourth
  • Fifth/Grad Student
  • Visiting Student
• Expected Year of Graduation*
• Major/Minor*
• How did you hear about the Black Bear Mentors Program? (check all that apply)
  • Orientation
  • Student Organization Fair
  • In-class Presentation
  • Website
  • Friend
  • Other
• Did a mentor refer you to the Black Bear Mentors Program?
• Do you have transportation?*
  • Yes
  • No
• Are you willing to drive others?*
  • Yes
  • No

• Pre-Interview Questionnaire

• What do you feel are the strengths you will bring to this program? (previous experience working with youth, bilingual, open and accepting mind, previous relevant volunteer experience, etc.)*
• Why have you chosen to participate in this program?*
• What are your hobbies or interests?*
• What clubs or groups, if any, do you belong to?*
• Availability: This program requires that you are available during after school hours once a week. You would need to be available at 2:00 pm for approximately 2 hours. Please check all days you are available at that time.*
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
• I understand that I will be subject to a national criminal background check, sex offender registry check, and review of my UMaine student conduct record in order to be accepted into this program.*
  • Yes
  • No
• 1. Within the past 10 years, have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance?*
  • Yes
  • No
• 2. Are you under current indictment or has a district/county attorney accepted an official complaint for any of the offenses in the above question?*
  • Yes
  • No
• If you answered YES to question 1 or 2 above, please explain:*

• Reference #1

• Name*
  First Last
• How do you know them?
  Employer/Supervisor (current or previous)Teacher/ProfessorAdvisor/CounselorCoachScout LeaderPastor/ClergyOther (cannot be relative or friend)
• Phone*
• Email*

• Reference #2

• Name*
  First Last
• How do you know them?
  Employer/Supervisor (current or previous)Teacher/ProfessorAdvisor/CounselorCoachScout LeaderPastor/ClergyOther (cannot be relative or friend)
• Phone*
• Email*
• Media and Web Release: The following consent allows the Black Bear Mentors program, the Division of Student Life, the University of Maine and other Black Bear Mentors program partners, such as BBBSMM, to use your name and any photographs we may take of you on/in our website, newsletter, social media, or other publications. Please give your consent by clicking YES below:*
  • YES, I give my consent for my photograph, videos and/or name to be used for publicity purposes by the Black Bear Mentors program, BBBSMM, and its partners.
  • NO, I DO NOT give my consent for my photograph, videos and/or name to be used for publicity purposes by the Black Bear Mentors program, BBBSMM, and its partners.
• Please read the following carefully and click on each statement to indicate your agreement.
  • I understand that all personal information will remain confidential and is used by UMaine/Black Bear Mentors staff and BBBSMM staff or Board for the purposes of creating and supporting a quality match.
  • I understand that this is an application for a volunteer opportunity and is not a promise or commitment by Black Bear Mentors or BBBSMM.
  • I certify that all information I have provided or will provide to Black Bear Mentors and BBBSMM, including this application, is true, correct and complete to the best of my knowledge. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would affect my application for a volunteer position. I understand that information contained on my application will be verified by Black Bear Mentors and BBBSMM . I understand that misrepresentations or omissions may be cause for my immediate rejection as an applicant or my termination as a volunteer.
  • At any time while involved with the Black Bear Mentors and BBBSMM programs, I agree to immediately inform my Black Bear Mentors/BBBSMM contact person of any and all infractions, violations, charges and convictions related to any civil, domestic, or criminal occurrences. This includes conduct violations. I understand that staff need to be fully informed to provide the best guidance or support possible.
  • I understand that I will not be accepted into this program if I have had a conduct violation for alcohol or other substances or violence against others in the last 12 months.
  • I understand that as a Black Bear Mentor, I am an ambassador for the University of Maine, and my actions will reflect on this program and the University of Maine.
• Signature: (Please enter your name below)
• Date
  MM slash DD slash YYYY

In complying with the letter and spirit of applicable laws and pursuing its own goals of diversity, the University of Maine System does not discriminate on the grounds of race, color, religion, sex, sexual orientation, transgender status, gender, gender identity or expression, ethnicity, national origin, citizenship status, familial status, ancestry, age, disability physical or mental, genetic information, or veterans or military status in employment, education, and all other programs and activities. The University provides reasonable accommodations to qualified individuals with disabilities upon request. The following person has been designated to handle inquiries regarding non-discrimination policies: Director of Equal Opportunity, 5713 Chadbourne Hall, Room 412, University of Maine, Orono, ME 04469-5713, 207.581.1226, TTY 711 (Maine Relay System).