Experience is not what happens to a man. It is what a man does with what happens to him
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Attachment A Who Is at Risk? Factors Identifying At-Risk Youth:
Attachment B Communities in Schools Description
Objectives
These objectives are achieved through CIS acting as a link between students and their families and other community-based organizations and agencies that provide direct support in the following areas:
Community Agency Service Providers
Attachment C Community Mentoring for Adolescent Development Support Service Providers
Attachment D CMAD Application, Page 1 Community Mentoring for Adolescent Development Application N A  ddress: Date of Birth: ____________________________
 Single Married
 No. of Children:
Ages of Children: D Permanent Phone: C A Employer: 
Business Address: 
C Previous Employment (within last 2 years): 
Educational Background (schools, degrees, & dates): 
Have you ever been a mentor with another group? No Yes
If yes, with what group? 
CMAD Application, Page 2 Have you been involved in other programs/activities involving young people? (Explain):
What is your main interest in becoming a mentor?
How long a commitment could you give to this program? 1 year 2-3 years 3-5 years 
How much time would you be able to offer on a weekly basis? 3 hours 4-5 hours more than 5 hours
Do you have any special qualities, talents, or interests that could be helpful in the program? 
Have you ever been charged/indicted for any criminal offense? No Yes If yes, please explain: 
Have you been convicted of any alcohol or drug related offenses? No Yes If yes, please explain:
H Have you ever had a problem with other drugs? No Yes
I
Do you speak any language(s) other than English? No Yes
I CMAD Application, Page 3
Phone #:
Name: Relationship:
A Phone #: 
Name: Relationship:
Address:
P Affirmation: I agree to adhere to the guidelines of Baylor University Policy and CIS/WISD Guidelines. The above information is true to the best of my knowledge. I grant permission to verify my employment and contact the references provided.
CONFIDENTIAL====================================================================================== School districts are now required by state law to obtain criminal history record information on all volunteers and applicants for employment (Texas Education Code Section 21.917). Communities In Schools is required by funders to follow similar procedures. Full Name ___________________________________________________ (Print) Last First Middle Social Security No. ______________ Date of Birth __________ Sex: [ ] Male [ ] Female Ethnicity: [ ] Black [ ] White [ ] Hispanic [ ] Asian [ ] Other
______________________________ _____________ Signature Date
CCS 1100-06 Syllabus—Fall
Class Meeting: Tuesday, 2:00–3:20 Director: Graduate Asst: Office: Health Center, Graduate Office Wellness Office Goals
Objectives
Expectations 1. Attendance and participation in class.* Baylor’s mandatory 75 percent attendance policy will be enforced for both semesters of participation. You may miss no more than three Tuesday class meetings during the first semester and still pass the course. Calling to notify a graduate supervisor of an anticipated or recent absence will not count as an absence if the absence is due to illness, death of a family member, or an otherwise excusable cause. *Missing your scheduled time with your mentee will also adversely affect your grade. If you are expecting to miss a meeting with your mentee you MUST notify your graduate supervisor (at the office or at their home telephone number) so that they can send word to the mentee, who will be awaiting the arrival of his/her mentor!!!! Once placement is assigned, you will spend at least two hours per week with your mentee. Even if the mentee is not there at the scheduled time, the two hours is still required. If the mentee repeatedly fails to come at the mutually scheduled time (at least two weeks consecutively), notify your graduate supervisor for help with the situation. 2. Journal keeping. Students are required to complete and turn in the journal form each Tuesday in class; they will be reviewed and returned the following week. Journal entries should be neatly written or typed on the form provided. Journals turned in on time may receive a grade of (+) that is worth one point. If a journal is turned in by the end of the week, the student will receive a (√) that is worth half a point. Journals turned in after one week will receive zero points (-). (Refer to the grading policy.) 3. Article/Book Review. You may choose to read three journal articles or one book—whichever you prefer—and complete a two-page, double-spaced report on the subject of mentoring and its effect(s) on adolescents in reference to your reading materials. If you choose to use an article not on the book/article list, the articles must come from reputable periodicals/journals (i.e., not People magazine, but perhaps Psychological Reports or Youth Today). The review should take an introspective look at the aspects, impacts, and/or unique qualities of mentoring discussed in the journal article. Due March. Grading 
I First Semester: Attendance*: 15 classes x 1 point each = 15 points Retreat: 2 days x 5 points each = 10 points Meetings with Mentee: 10 meetings x 5 points each = 50 points Journals: 10 journals x 1 point each = 10 points Article Review: 1 report x 10 points = 10 points Reflection Paper: 1 paper x 5 points = 5 points
Meetings with Mentee: 10 meetings x 5 points each = 50 points Returning Mentor Meetings: 4 meetings x 7.5 points each = 30 points Experience Summary: 1 review x 20 points each = 20 points
Students will receive their final grade for CCS 1100 sec. 06 after completing two semesters of mentoring service at a specified middle school. This requires the mentors to commit at least two semesters to the program in order to fulfill the criteria for the course as agreed upon acceptance into the program. At the end of the first semester, students will receive an IN PROGRESS on their grade report, which will be replaced with the earned grade at the end of their second semester. During the second semester, students do not attend the mentoring class. Please notice that the second semester activities contribute to half of the overall grade. Second semester mentors continue their relationship with the same middle school student (unless circumstances necessitate a rematch) for at least two hours per week and *attend several mandatory continued-training meetings and write an experience summary in order to complete the requirements for the course. Course Outline Community Mentoring for Adolescent Development CCS 1100-06 Fall ================================================================= September: 2 Introduction/Orientation 9 Stages of a Mentoring Relationship Interest Inventories 13 Retreat (Mandatory for all mentors) 16 CIS Orientation 23 Mentoring Assignments Given 30 Listening and Communication Skills October: 7 Developmental Stages 14 Self-Esteem Building 21 Goal Setting and Decision-Making Report Due!! 28 Cultural Sensitivity
11 Cultural Sensitivity 18 Conflict Resolution Video: “Working with Hostile Teens” 25 CIS Mid-Term Update
9 Final Week of Mentoring at Middle Schools Last Journal Due Briefing on Responsibilities for Returning in Fall Mentoring Guidelines 1. Students must sign up for a two-hour mentoring period between 3:30–6:30 p.m. for one day between Monday and Thursday. The scheduled mentoring time and day at the appointed WISD middle school should be adhered to for the entire semester. If a mentoring time needs to be modified, mentors should notify the graduate supervisor responsible for scheduling. Using student and mentor profiles, we will match mentors with prospective mentees. 2. Once mentoring begins at the designated WISD middle school, students are to sign in and out in the Baylor Mentor Notebook located with the after school Lighted School Outreach Coordinator. If a mentor does not sign this list when mentoring, credit will not be recorded. 3. Students must mentor two hours per week. Exceptions include Baylor or WISD school holidays on scheduled mentoring days with mentees—these are the only days that a mentor may miss a meeting and not subsequently make up the time. Mentors who need to reschedule a weekly meeting because of an emergency and/or illness should call their graduate supervisor as soon as possible. This will enable the supervisor to notify your mentee of your absence and of the rescheduled time. The student should accumulate 20 hours of mentoring time during each semester; because consistency is essential, the weekly hours will be monitored carefully over the semester. 4. If a mentee is terminated from the Lighted Schools program, or the mentor/mentee relationship is unsuccessful, then you will be re-matched as soon as possible. If the Coordinator makes a rematch, mentors must report the change to the graduate assistant responsible for scheduling. Your specific graduate assistant will help you rematch if needed. 5. Mentors are required to contact their mentee’s parent(s) or guardian(s) to explain the goals of the mentoring program, the personal goals for the mentoring relationship, their child’s progress, and upcoming activities. Contact with mentee’s parents should be made at the beginning of the mentoring relationship and at least once per month thereafter. The contact with mentee’s parents will give mentors more background information on their mentee and will increase parental involvement. 6. Returning mentors are required to attend monthly meetings in order to track their progress with their mentees and participate in further training. It is the mentor’s responsibility to inform his/her graduate assistant of a change in address or phone number before the start of the new semester. These returning mentor training meetings are mandatory for a grade to be determined in the course. Various materials, including this syllabus, will detail information necessary to the proper conduct of the second semester activities. These materials will be given at the end of the first semester and it is solely the mentor’s responsibility to keep up with this information and be in attendance when required. 7. Reflection papers will be written at the end of the first semester of the program. Each student will write a two-page reflection on his/her participation in the program thus far. The paper should attend to the impact the student believes he/she has had on the assigned mentee, the Mentoring program, the Lighted Schools program, etc., as well as what he/she has learned/experienced from his/her involvement. 8. Experience summaries will also be written at the end of the second semester of participation. This assignment will be very much like the reflection paper assignment but more comprehensive and reflective in nature. Attachment F Journal Form Community Mentoring for Adolescent Development CCS 1100
Mentee: _________________________ 1.) Describe this week’s mentoring activities. 2.) Discuss the state of your mentoring relationship. Evaluate the progress, setbacks, etc., of your relationship. 3.) Describe your plans for your next meeting. 4.) Describe any problems you encountered with the Mentoring Program. 5.) Describe any contact made with the CIS staff, Lighted School Site Manager, or your mentee’s parents. Attachment G Student Interest Inventory, Page 1 Student Interest Inventory Name _____________________________ Grade _________ Female ______ Male Address Telephone Number _______________________ Date of Birth Parent/Guardian Name Who do you live with? Circle One: My parents are: Single Married Divorced Widowed Do you work? _______ Where? _____________________ Title? How many brothers/sisters do you have? What school subject would you like help with? Why? Have you ever thought about quitting school? What areas can you improve on in school? Hobbies: ____ Crafts ____ Music ____ Sewing ____ Computers ____ Cooking ____ Basketball ____ Golf ____ Reading ____ Football ____ Baseball/Softball ____ Art ____ Biking ____ Tennis ____ Skating/Rollerblading ____ Writing ____ Working out Other
Any collections (stamps, baseball cards, etc.)? What do you plan to do when you graduate? Do you want to go to college? _____ Yes _____ No Would you like help planning career choices? _____ Yes _____ No What would you like your “mentor” to be like? Would you prefer a: ____ male ____ female _____ either Are you willing to commit to spending two hours of Lighted School time each week with
Why do you want a mentor? Student Interest Inventory, Page 2
____ quiet ____ outgoing ____ happy ____ loving ____ shy ____ talkative ____ moody ____ sensitive ____ nervous ____ friendly ____withdrawn ____ energetic ____ insecure ____ a leader ____ bored ____ loyal ____ lonely ____ honest ____ athletic ____ confused ____ dumb ____ wonderful ____ talented ____ upset ____ hardworking ____ serious ____ musical ____ clumsy ____ dependable ____ a follower ____ confident ____ lazy ____ a listener ____ mixed up ____ timid ____ smart ____ silly ____ average ____ calm For Office Use Only: (check applicable items)
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ame: Soc. Sec. No.: ____________________________
No Yes Local Phone:
lassification:
f yes, please list:
hone #:
