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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UM COMPOSITOR LUSITANO NO MARANHÃO IMPERIAL Professor Adjunto da Universidade Federal do Piauí O presente estudo trata de questões referentes ao compositor português António Luiz Miró e sua passagem pelo Maranhão na primeira metade do século XIX. Faz parte de um projeto desenvolvido no Núcleo de Pesquisa em Música, da Universidade Federal do Piauí sob minha coordenação, em que se

Microsoft word - 2010 camper registration form

MT. LEBANON ENCAMPMENT PO Box 427 - Cedar Hill, Texas 75106-0427 972-291-7156 - 972-291-4958 (Fax) - CAMPER REGISTRATION FORM 2010 Name: _________________________________________________________________ Date of Camp: _____________________Sex: (M/F) _______ Birth Date: _________________________________ Age: _______ Grade Completed by End of School Year 2010 __

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