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