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NJ GEAR UP Mentors

Mentoring Overview

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.


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
Date of Birth:
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.:
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

Jersey City
Penns Grove-Carneys Point
Atlantic City/Pleasantville

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: 
Relationship to you: 

2. Name: 
Years known: 
Relationship to you: 


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

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.

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