Microsoft word - mentor application 08 _2_.doc

Name: __________________________________________________ Street Address: ___________________________________________ City: _____________________________ Zip:___________________ Daytime Phone: _______________ Evening Phone: ___________ Email Address:____________________________________________ Highest Level of Education Completed: Current College students please fill out the following section: College: ______________________________________ Major: ______________________ Year: Freshman Sophomore Junior Senior Your Campus Address (if different from above): ____________________________________________________________________________ Your Campus Phone #: ________________________________ Email:_________________

List three non-family members who know you well and can attest to your Name: ________________________Relationship to you: _________________ Address: __________________________________________________________ Phone/email: ______________________________________________________ REFERENCES (continued) Name: ________________________Relationship to you: _________________ Address: __________________________________________________________ Phone/email: ______________________________________________________ Name: ________________________Relationship to you: _________________ Address: __________________________________________________________ Phone/email: _______________________________________________________ EMPLOYMENT Current place of employment (We reserve the right to contact employer for reference check)
Employer: _____________________________________________________________
Your Occupation:______________________ Dates of Employment _____________
Business Address: _______________________________________________________

Please list relevant experiences to Mentoring (i.e. tutoring, Big Brother/Big Sister, etc.):
Why would you be a good mentor? ______________________________________
What do you feel are your strengths and weaknesses? _______________________
Your Hobbies and Interests: _____________________________________________
Do you have reliable transportation to get to and from regular mentoring meetings?
Yes No
Have you ever been convicted of a crime? Are you currently being prosecuted for a crime? If yes to either question, please explain: ________________________________________________________________________________________________________________________________________________ ______________________________________________________________ AVAILABILITY – What are the best days and times for you to mentor? ___________________________________________________________ ___________________________________________________________ In making this application to be a volunteer mentor, I understand that the Mentoring Program routinely does criminal, child abuse registry and driving record checks of volunteer mentors. I authorize the Mentoring Program to conduct these checks. I certify that all the information provided on this application is true and accurate to the best of my knowledge. Should any information on this application change, I agree to notify the Mentoring Program Coordinator in writing within (30) days. Signature: ________________________________________ Date: _______________________ Please be advised that receipt of your application does not guarantee acceptance into a Lamoille Valley Mentoring Partnership Mentoring Program. Our decision to accept is based upon several factors, including your application, your references, a criminal background check, and our assessment of suitability from information collected from these sources and during the interview.
School-based mentoring programs:
mentoring programs:

Cambridge Elementary
Peoples Academy
Lamoille County Court
Middle/High School
Justice Programs, Inc.
Craftsbury Academy
Stowe Elementary
Lamoille County
Mental Health
Eden Central School
Stowe Middle & High
Lamoille Family Center
Hardwick Elementary
Waterville Elementary
Hazen Union High School
Laraway Youth &
Wolcott Elementary
Family Services
Hyde Park Elementary
Woodbury Elementary
Social Services
Not sure where you’d like to mentor?
Send your application to:
Lamoille Union
Middle-High School
Buffalo Mountain School

Morristown Elementary

Clarina Howard
Nichols Center


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