Mentoring Services Sioux Falls

If you are interested in becoming a mentor, please complete the fields listed below and click Send Now.

Please also complete the attached release for a criminal background check. Note: Both the application and release forms must be completed in order to apply to become a mentor.

Contact Information

First Name *REQUIRED*

Last Name *REQUIRED*

Middle Initial *REQUIRED*

Gender *REQUIRED*

Male
Female

Home Address *REQUIRED*

City, State, Zip *REQUIRED*

Home Phone *REQUIRED*

Work Phone *REQUIRED*

Cell Phone *REQUIRED*

Email *REQUIRED*

Best Contact Method *REQUIRED*

Home
Work
Cell
Email

Prefer call in *REQUIRED*

a.m.
p.m.

Employer Name

Job Title

Number of Years with Employer

Employer Address

City, State, Zip

Are you receiving college credit or participating in the program as part of a college course

If Yes, name of college

Referring Professor

Have you ever been convicted of a drug charge? *REQUIRED*

If so, charge

Have you ever been convicted of a criminal offense? *REQUIRED*

If so, charge

Have you ever been convicted of abuse, neglect, or assault? *REQUIRED*

If so, charge

School Preference

Mentoring programs are offered in the following schools. Please check your preference.

I am volunteering as a *REQUIRED*

School-Based Mentor
USucceed Mentor

Sioux Falls High

Roosevelt
Lincoln (USucceed only)
Washington (USucceed only)
New Tech

Baltic

Baltic Elementary

Brandon Valley

Canton

Lawrence Elementary
Canton Middle
Canton High

Dell Rapids

Dell Rapids Elementary
Dell Rapids Middle
Dell Rapids High

Garretson

Garretson Elementary
Garretson Middle
Garretson High

Lennox

Lennox Elementary
Worthing Elementary
LWC Middle

Tea Area

Tea Elementary
Tea Intermediate
Tea Area Middle
Tea Area High

Tri-Valley

Tri-Valley Middle
Tri-Valley High

West Central

Hartford Elementary
Humboldt Elementary
West Central Middle
West Central High

Referral Information

Please provide any additional referral details

Matching Information

I prefer to work with a specific age

If volunteering as an in-person mentor, I am available the following days/times during school hours (typically 8-3):

Monday

Tuesday

Wednesday

Thursday

Friday

Please list any other information about yourself you feel would be helpful in matching you with a student. This can include any special hobbies, talents, or interests.

Please describe any previous experience working with children.

Why are you interested in becoming a mentor?

References

Please list three non-family references. Please provide complete information to expedite your application.

1st Reference

Name

Relationship

Primary Phone

Secondary Phone

Primary Email Address

Secondary Email Address

2nd Reference

Name

Relationship

Primary Phone

Secondary Phone

Primary Email Address

Secondary Email Address

3rd Reference

Name

Relationship

Primary Phone

Secondary Phone

Primary Email Address

Secondary Email Address

Emergency contact name *REQUIRED*

Relationship *REQUIRED*

Phone *REQUIRED*

Mentor Agreement

Please check yes or no to confirm your understanding of the program guidelines. Thank you for carefully reading before completing.

By checking yes or no, I hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of the school and the Mentoring Programs. I affirm that:

For All Mentors

The information I have provided in the application may be verified, and I give permission to the school district listed above and Lutheran Social Services of South Dakota to make inquiry of others concerning my suitability to act as a volunteer. *REQUIRED*

In the course of volunteering as a mentor, I may be dealing with confidential information, and I agree to keep said information in the strictest confidence. This means that I will not discuss my student’s personal problems publicly or with others. *REQUIRED*

If I need help, I will seek the assistance of the school site coordinator or Mentoring Program staff. I understand that this confidentiality does not apply to suspicions I may have about abuse, neglect, illegal activity, or suicide. *REQUIRED*

If these issues arise, I will immediately contact the school or program personnel. *REQUIRED*

The relationship between the school district and volunteers is an “at will” arrangement, and that it may be terminated at any time without cause by the volunteer, the school district, or Lutheran Social Services. *REQUIRED*

I agree to attend new mentor training. *REQUIRED*

I will be a positive role model to my mentee. *REQUIRED*

I agree to abide by the policies and guidelines of the mentor program and the school in which I volunteer. I understand that failure to do so may result in termination of the mentoring relationship. *REQUIRED*

For School-Based Mentors

I understand that all mentor activities shall take place during the school day, on school grounds, or at school-sponsored events at which school personnel are in attendance. *REQUIRED*

Yes
Does not apply

I will visit with my mentee 30-60 min. per week at school during the school day or at school-sanctioned events through the school year and any subsequent school year that I participate. If I cannot attend, I agree to contact the school in advance. *REQUIRED*

Yes
Does not apply

I am encouraged to contact the school before a scheduled meeting to verify that the student is in attendance unless the school has specifically indicated that they will contact me. *REQUIRED*

Yes
Does not apply

I am willing to commit to one school year in the program and will be asked to renew my participation in subsequent years. *REQUIRED*

Yes
Does not apply

For USucceed Mentors

I understand that I will meet with my student for at least one school semester on school grounds and then will be able to meet in public locations throughout the community. *REQUIRED*

Yes
Does not apply

I will meet with my student for at least one hour per week or four hours per month throughout the year. *REQUIRED*

Yes
Does not apply

I will participate in an additional training, submit to additional background screening (fingerprinting, auto insurance, etc). I will actively participate and respond in monthly USucceed Mentor Check-Ins. *REQUIRED*

Yes
Does not apply

I am committing to four school years in the program or until my mentee completes high school. *REQUIRED*

Yes
Does not apply

Current Date

By clicking here, I certify that all the information I have provided in the application above is accurate. *REQUIRED*

Lutheran Social Services of South Dakota

Mentor Volunteer Application

Contact Information

School Preference

Referral Information

Matching Information

References

Mentor Agreement

For All Mentors

For School-Based Mentors

For USucceed Mentors