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: _______________________________________________________ Phone/email:___________________________________________________________ GENERAL INFORMATION 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: Community-Based mentoring programs: Cambridge Elementary Peoples Academy Lamoille County Court Middle/High School Diversion/Restorative 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
GastroMend-HPTM THIS INFORMATION IS PROVIDED FOR THE USE OF PHYSICIANS AND OTHER LICENSED HEALTH CARE PRACTITIONERS ONLY. THIS INFORMATION IS INTENDED FOR PHYSI-CIANS AND OTHER LICENSED HEALTH CARE PROVIDERS TO USE AS A BASIS FOR DETERMINING WHETHER OR NOT TO RECOMMEND THESE PRODUCTS TO THEIR PATIENTS. THIS MEDICAL AND SCIENTIFIC INFORMATION IS NOT FOR USE BY CONSUMERS. THE DIETARY SUPPLEMENT