MENTOR Memphis Grizzlies Affiliate Application

Please complete this application if you are interested in becoming an Affiliate organization of MENTOR Memphis Grizzlies.

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* 1. Program or Organization Name

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* 2. Year Organization Founded

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* 3. Federal ID Number/ 501 (c)(3) Status

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* 4. Street Address

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* 5. Phone Number

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* 6. Executive Director Contact Information

Name

Email Address

Phone Number

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* 7. Mentoring Program Manager/Coordinator

Name *

Position

Email Address *

Phone Number *

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* 8. Additional Mentoring Program Staff

Name

Position

Email Address

Phone Number

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* 9. Additional Mentoring Program Staff

Name

Position

Email Address

Phone Number

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* 10. Additional Mentoring Program Staff

Name

Position

Email Address

Phone Number

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* 11. Additional Mentoring Program Staff

Name

Position

Email Address

Phone Number

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* 12. Additional Mentoring Program Staff

Name

Position

Email Address

Phone Number

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* 13. How long has your mentoring program been in operation?

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* 14. How did you hear about MENTOR Memphis Grizzlies?

Other (please specify)

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* 15. What are you hoping to get out of a partnership with MENTOR Memphis Grizzlies?

Technical Assistance

Funding Opportunities

Training/Professional Development

Recruitment Support

Grizzlies Affiliation (name recognition, access to special events, game tickets, etc)

Networking & Exposure Opportunities

Other (please specify)

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* 16. What mentoring model(s) does your program utilize?

One to One - one adult matched with one young person

Group - one adult matched with multiple youth

Team - multiple adults matched with multiple youth

Peer - youth matched with another youth

Other (please specify)

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* 17. Where does mentoring take place?

Site-based

School-based

Community-based

Other (please specify)

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* 18. How many youth does your program currently serve?

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* 19. How many mentoring matches does your program currently have?

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* 20. How many mentors does your program currently have?

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* 21. What is your match capacity? (how many matches can your program support)

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* 22. Does your program serve a specific population or have a special focus? Please explain below.

Mentor Screening

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* 23. What is your minimum age requirement for mentors?

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* 24. Do you require a written application for your mentors?

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* 25. Does your program conduct an FBI Fingerprint Check for your mentors?

Yes

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* 26. Does your program conduct in-person interviews with mentors?

Yes

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* 27. Does your program conduct pre-match training for mentors?

Yes

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* 28. Please upload any materials or collateral about your program you would like to share.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

Choose File