Community Connections

Berlin, Calais, East Montpelier, Middlesex, Montpelier, Worcester

      Bringing School and Community Together

 

Girls First/Boyz First Mentoring Project      

Mentee Application

 

Date Received:

 

We are glad that you want a mentor! Please answer these questions so that we can try to make the best "match." If you do not feel comfortable answering a question, you may leave it blank. The more we know about you, the better we can match you with your mentor.

 

Name: __________________________________________________________

(last)                                          (first)                                                  (middle)                

 

Address: ________________________________________________________

 

_______________________________________________________________

 

Telephone Number(s): _______________________________________________

                                   (home)                                                        (work)

E-Mail Address____________________________________________________

 

Parent's/Guardian's Name____________________________________________

 

Parent's/Guardian's phone_______________________________

 

Parent's/Guardian's Address (if different)

 

 

Is any parent currently incarcerated in the state of Vermont or elsewhere?  Yes__No__

 


Birthdate: Month/        Day/                 Year                 Sex:   M               F

 

School___________________Grade______________Teacher_______________

 

Favorite subject__________________ Least favorite subject________________

 

 

 

 

What activities, clubs, sports, are you involved with?

 

 

What are your hobbies?

 

 

Are you currently taking any medications?  For what conditions?

 

 

Doctor’s name and phone number____________________________________

 

Person and phone number to be contacted in case of emergency if parent cannot be reached ______________________________________________________

 

 

When would you like to meet with your mentor? (check all that apply)

                  

 


After school          what days and times________________________________

 


Weekends              what day(s) and times_______________________________           

 

I am . . .

Talkative_____     Quiet_____     Friendly_____    Shy_____     Funny_____

 

Serious_____     High-energy_____    

 

When I grow up I want to be . . .

 

 

 

I want a mentor because . . .

 

 

I like to . . .

 

 

Please return forms to: Wendy Farber, 490 Center Road, Middlesex, VT 05602