Eye to Eye Mentor Application

Page 1

Eye to Eye
Eye to Eye is a national mentoring program that pairs kids with learning differences (LD) and ADHD with similarly labeled college and high school students. Our Mentors use a weekly art-based curriculum to help students with LD/ADHD to value their unique minds, build their self-esteem, and develop essential social-emotional skills.  Our vision is to create a world in which people with LD/ADHD are fully accepted, valued, and respected by themselves and others.

  • Have ADHD or a language, math, or reading-based learning disability as a primary diagnosis
    • Ex: Dyslexia, dyscalculia, dysgraphia, auditory processing disorder, visual processing disorder
  • Be at least 16 years old
  • Be currently enrolled as a student, preferably at a Mentor school
  • Complete the Mentor Enrollment Form and Mentor Agreement
  • Pass a criminal history background check
  • Adhere to all program policies and procedures
  • Be trained by an Eye to Eye National staff member
  • Communicate with respect and without judgment to all chapter members, including those of different backgrounds
  • Be a positive role model for Mentees and fellow Mentors
Eye to Eye Mentors will help Mentees with the following:
  • Developing metacognition (an understanding of their minds)
  • Building self-esteem
  • Identifying personal strengths
  • Learning about accommodations in school
  • Developing self-advocacy skills
  • Setting life and educational goals
  • Building a supportive LD/ADHD community
Mentors are expected to:
  • Serve as a Mentor for at least one semester and preferably for one academic year
  • Attend all Eye to Eye Art Rooms (1-2 hours/week)
  • Be dependable and consistent in attending Eye to Eye events
  • Notify the Chapter Leaders if they are unable to attend an art room
  • Help Chapter Leaders find a replacement Mentor if they are no longer able to participate as a Mentor
Mentors have the ethical obligation to do no harm. This encompasses the more extreme forms of harmful behavior, such as sexual harassment, abuse and exploitation. A number of other behaviors also clash with Eye to Eye's values and standards and are therefore prohibited while participants are engaged in mentoring activities or engaging with any chapter member, including Mentors, Mentees, teachers, parents, and other volunteers. Mentors understand that any violation of Eye to Eye's rules and code of ethics may be grounds for removal as a Chapter Leader or Mentor, a decision made by the chapter's National Program Coordinator.
The following behavior is prohibited:
  • Engaging in any unwelcome and unwanted physical or verbal conduct, such as inappropriate touching, patting, pinching, punching, or assault, or the use of exploitative language in either a sexual or nonsexual nature, including threats of such behavior.
  • Physically disciplining, hitting, striking, or threatening a Mentee -- even in so-called "play."
  • Using disrespectful language, including swearing, in the presence of students.
  • Using, possessing or being under the influence of alcohol, marijuana, or illegal drugs.
  • Smoking or use of tobacco on school grounds or in the presence of children.
  • Engaging in flirtatious behavior with a Mentee, expressing romantic feelings towards a Mentee in any form, engaging in a romantic or sexual relationship with a Mentee, stalking a Mentee, or engaging in sexual exploitation with a Mentee and any other chapter member.
  • Making unwanted sexual advances or drawing unwanted sexual attention towards other community members.
  • Use of denigrating language, public or private, directed toward any chapter member.
  • Displaying demeaning, suggestive, or pornographic material.
  • Privately giving a Mentee or his/her family money or an expensive gift or accepting money or expensive gifts from a Mentee or his/her family.
  • Meeting alone with a Mentee. All mentoring activities must be performed in a group setting. All activities will be on school grounds except for sanctioned Eye to Eye field trips.
  • Exchanging contact information and/or communicating with Mentees outside of Eye to Eye art rooms, including via private email, text, social media or live chat conversations, unless approved by the National Program Coordinator.
  • Possessing or using firearms, firecrackers, explosives, toxic or dangerous chemicals, fire, or other lethal weapons, equipment, or material while working with Mentees or participating in any Eye to Eye activity.
  • Violating any local, state, or federal law, or any safety policies of the college or high school chapter school or Mentee School.
  • Mentors must immediately report accidents or injuries to the Chapter Leaders. The Chapter Leaders will report the incident to their Eye to Eye National Program Coordinator.
  • Mentors must inform the Chapter Leader of any difficulties or areas of concern that arise in the mentoring relationship. Chapter Leaders can provide insight on how to address any challenges.
  • There may be instances when a Mentee's behavior is unacceptable. Explain to the Mentee why his/her behavior is unacceptable, but never use ultimatums. Ask for help from a Chapter Leader if you have difficulty managing your Mentee's behavior.
  • Hugs, within the group environment, are appropriate if both the giver and receiver of the hug are comfortable. Ask, "Is it okay for me to hug you?" Likewise, if you do not feel comfortable receiving a hug from a child, tell him or her this in a gentle way and suggest an alternative, such as giving a high five or putting your hand on his or her shoulder or arm.
  • If Mentors need to go to the bathroom during the art room, they should do so alone. Should a Mentee need to use the bathroom, a Mentor should escort him/her with another Mentee but wait outside of the bathroom.
  • Mentors are asked to respect the privacy of the Mentees and their families. Mentors should not discuss matters or information concerning Mentees outside the art room or with anyone other than the Chapter Leaders or National Program Coordinator.
  • Mentors must follow the dress code outlined by the Mentee School.
  • Mentors must follow Mentee School entrance and student release from school protocol.

Page 2

Mentor Information

Optional Questions
The following set of questions is optional, but your answers will help Eye to Eye to learn more about our work and how to improve it.

Page 3

Parent/Guardian Information

Page 4

Mentor Agreement
I understand that Eye to Eye staff have final right to accept applicants into the program at their sole discretion, and that Eye to Eye staff reserve the right to terminate any Mentor from the program at any time for any reason. I certify that I am at least 16 years of age. I will follow all rules and guidelines as outlined by Eye to Eye staff, Mentor training, program policies, and this contract.

I certify that I have not been convicted of any felony or misdemeanor classified as an offense against a person or family, of public indecency, or a violation involving a state or federally controlled substance. I hereby certify that I have never been accused, arrested, charged, or convicted of child abuse. I am not under current indictment. 

I give permission for Eye to Eye program staff to conduct a criminal background check and verify any and all information provided by me on this application as part of the screening for entrance into the program. I consent to the preparation of background reports by Verified Volunteer, a background check company, and to the release of such reports to Eye to Eye for the purpose of assisting Eye to Eye in making a determination as to my eligibility to be a volunteer.  I understand that, to the extent allowed by law, information contained in my application or otherwise disclosed to Eye to Eye by me before or during the volunteer period, if any, may be utilized for the purpose of obtaining such consumer reports and/or investigative consumer reports about me. I authorize law enforcement agencies, learning institutions, information service bureaus, credit bureaus, record/data repositories, courts (federal/state/local), motor vehicle record agencies, the military, and other individuals or sources to furnish any and all information on me that is requested by the consumer reporting agency. For more information about your rights under the Fair Credit Reporting Act, visit www.consumerfinance.gov/learnmore/

I understand that the program takes place solely within the scheduled sessions, exclusively at the program location, and I agree to limit my actions to the activities permitted within the confines of the program’s policies. I understand that any relationships or contact established between Mentor/Mentee and family members beyond the organized and supervised activities of the program are neither encouraged nor condoned. I understand that upon the ending of the academic year, future contact with my Mentee is beyond the scope of Eye to Eye and may happen only by the mutual consensus of the Mentor, the Mentee, a representative of the Mentee School and parent/guardian. If future contact is agreed upon, Eye to Eye will not be responsible for monitoring and supporting the match after the match has ended and Eye to Eye will not be liable for any incidences that occur after the match has closed.

Page 5

Research Survey Questions

Your participation in this survey will help us learn more about the positive impact of mentoring from the Eye to Eye program.

This is a research study, and you do not have to take part. If you have any questions, you may contact the study coordinator, Stephanie Haft, at Stephanie.Haft@ucsf.edu.

In this study, the researchers are doing a survey to learn more about the impact of mentoring for students with learning differences.

If you agree to take part in this study, you will complete a survey online on this form. It will take you about 10 minutes to complete the survey. Additionally, you agree for Eye to Eye to release your de-identified information on this form to UCSF for research purposes.

We will do our best to protect the information we collect from you. Information which identifies you will be kept secure. You will not be paid for completing the survey. There are no costs to you.


Thank you!


Here is a list of things that happen to people and that people think, feel, or do. Read each sentence, carefully, and choose the one answer on a 1 to 5 scale that tells about you best. THERE ARE NO RIGHT OR WRONG ANSWERS.

Never Rarely Sometimes Often Almost Always
Group Identification

We are all members of different groups and categories.  Respond to the following statements on the basis of how you feel about having a learning difference.  There are no right or wrong answers to any of these statements; we are interested in your honest reactions and opinions.

Please indicate how much you agree or disagree on a scale of 1 to 7 with each of the following statements by choosing the one number from the scale on the answer sheet that comes closest to your view.

Strongly Disagree Moderately Disagree Slightly Disagree Neither Agree nor Disagree Slightly Agree Moderately Agree Strongly Agree
1 2 3 4 5 6 7