Vermont Mentoring Database


Our mentors serve as a role model, active listener & caring friend to a child living in Marshfield or Plainfield. By engaging their mentees in positive activities, mentors teach children the opportunities available to them through a respectful friendship with an adult. Mentors in our community-based program are carefully matched with a child who shares similar interests. Matches meet in the community 2-4 times monthly, doing activities they both enjoy. This volunteer opportunity is a 12-month commitment occurring in the afterschool hours. To find out more about this program or learn more about our school based literacy mentoring opportunity contact program director Pam Quinn at pamquinn@twinfield.net

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Basic Information
* First Name
Preferred Nickname or Salutation
Middle Name
* Last Name
Prefix
Suffix
Other names you have used (including maiden name)
Home Address
* Home Address Line 1
Home Address Line 2
* Home City
* Home State
* Home Zip code
Previous Residences
Please list all residences you have lived in during the past five years. If you have not moved during that timeframe, you can leave this question blank.
Address 1Address 2CityStateZip
Previous Residence 1
Previous Residence 2
Previous Residence 3
Previous Residence 4
Previous Residence 5
Employment Status
Employment Status
Other Employment Status
Current Job Title
Business Address
* Current Employer
Work Address Line 1
Work Address Line 2
Work City
Work State
Work Zip code
Mailing Address
* Set mailing address
Home AddressBusiness Address
Employment
Previous Employment
Please list all of your previous employers from the past five years. If you have not changed jobs during that timeframe, you can leave this question blank.
Employer NameStart DateEnd Date
Previous Employer 1
Previous Employer 2
Previous Employer 3
Previous Employer 4
Previous Employer 5
Contact Information
Email address
Alternate email address
* Home phone
Work phone
Work phone ext.
Cell phone
Fax
May contact at work
YesNo
Website
Demographics
* Date of Birth
* Gender
Other (please specify)
* Ethnicity
Other (please specify)
Marital status
Education level
Other education
If you are currently in school, what is the status of your schooling?
* Emergency contact name
* Emergency contact phone
Emergency Contact Relation to Applicant
Members of Household
NameAgeGenderRelationship
References
Please list at least three references whom the agency may contact in support of your application to become a mentor. At least one reference must be a professional reference who has known you for at least six months unless there are extinuating circumstances. Personal references need to have known you for at least two years.
NamePhoneEmailRelationshipLength of Relationship
Reference 1
Reference 2
Reference 3
Reference 4
Reference 5
Application Information
* How did you hear about this program?
* Other (please specify)
What website?
Name of Friend
What advertisement?
What Radio or TV Show
Which mentoring agency?
What school?
What event?
Disability and/or Additional Needs
Please describe Disability and/or Additional Needs
Preferred School or Community
Why are you interested in mentoring?
Please list any previous mentoring experience and/or work with youth.
Why do you think you would be a good mentor?
Certifications
What are your personal goals?
Preferred Age of Child
What are your interests and hobbies?
Other Interests
If you speak any other languages (in addition to English), please list below
* Do you have reliable transportation?
YesNo
* Do you have a drivers license?
YesNo
* Do you carry automobile insurance?
YesNo
* Do you understand the commitment is for at least one year or school year?
YesNo
If this program is not the right fit for you, would you be interested in learning about other mentoring opportunities in your area?
YesNo
Additional Information
* Are there pending criminal charges against you?
YesNo
* Have you been convicted of any felony or misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance?
YesNo
* Have you ever been arraigned for or convicted of child abuse or neglect or of sexually abusing or molesting a youth 18 or younger?
YesNo
* Have you ever received treatment for alcohol or substance abuse?
YesNo
* Have you ever been treated or hospitalized for an emotional/psychiatric condition?
YesNo
* Other than the above, is there any fact or circumstance involving you or your background that could call into question your being entrusted with working with youth?
YesNo
If you answered yes to any of the above seven questions, please explain.Please note that answering yes does not automatically disqualify you from becoming a mentor.
* Please list any state(s) other than Vermont of which you have been a legal resident.
* I would like to work with a child who is: male, female, no preference
Availability
What are the best days of the week & times for you to mentor?
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Mornings
Afternoons
Evenings
Release Information
Media Release
The term ‘Agency’ is defined as the agency listed in the first field below.
Agency
Twinfield Together Mentoring Program 
* I agree to have my photograph or remarks published for the Agency In related media pieces, newsletters, web pages or other documentation in support of the mentoring program at the Agency.
YesNo
* I also agree to allow the Agency to grant permission, at its discretion, to Mobius, Vermont’s Mentoring Partnership, to have my photograph or remarks published in related media pieces, newsletters, web pages or other documentation in support of promoting the mentoring cause statewide.
YesNo
Application Information Release
I understand that I have made an application for a volunteer opportunity with the Agency and it is not a commitment or promise of a volunteer opportunity by the Agency. I understand that it is in the Agency's discretion whether to accept me as a mentor and the Agency has no obligation to provide me with a reason for its decision to accept or reject me as a mentor.

I represent and warrant to the Agency that all information that I have or will provide to the Agency during the selection process, including information on this application and in interviews with Agency, is true, correct and complete to the best of my knowledge. I further agree that I have and will answer all questions posed by the Agency to the best of my knowledge and that I have not and will not withhold any information that would unfavorably affect my application for a volunteer position. I understand that any misrepresentations or omissions by me may be cause for my immediate rejection as an applicant for a volunteer position with the Agency or my termination as a volunteer.

I hereby authorize the Agency to request and obtain any and all records, documents and information about me from employers, agencies and references included on my application necessary for the Agency to evaluate my suitability as a mentor. I understand that the Agency will check some or all of the following: my records on the national sex offender registry, the Vermont child abuse and neglect registry, the Vermont criminal conviction search, FBI Fingerprint-based Background Check, and Vermont Motor Vehicles Driver Record Check. I hereby consent to the release of such records, documents, and information to Agency and to the Agency’s designated representatives. I release and agree to defend and hold harmless from liability any person or organization that provides information.

I agree and acknowledge that this information may be disclosed by Agency officials to persons involved in the implementation of Agency activities and programs. I hereby release and agree to defend and indemnify the Agency, its directors, officers, partners, employees, affiliates, agents, successors, and its designated representative from any and all claims that may result from the use, release and disclosure of such information.

I HAVE CAREFULLY REVIEWED THIS "INFORMATION RELEASE AND COVENANT NOT TO SUE" AND I HEREBY CONFIRM MY UNDERSTANDING OF ITS CONTENTS AND AGREE TO BE BOUND BY ITS TERMS AS A CONDITION OF MY PARTICIPATION IN THE ABOVE ACTIVITY.
* * I have read and understood the terms outlined above, and agree to them.
I agree to inform the Agency if any of the information on this application changes or if I’m convicted of a crime (misdemeanor or felony) during the time that I am involved with the Agency.
I am 18 years of age or older.