Community Friends Mentor Application

Community Friends Mentee Application Form

Community Friends

210 Adirondack House
Center for Education in Action
Middlebury College
Middlebury, VT 05753

802.443.3010 phone
802.443.2990 fax
E-mail

Child's Name:

Date:

Gender:

Date of Birth:

Home Address:

Home Phone:

E-mail:

Alternate Phone:

School Attending (if applicable):

Is there someone able to provide transportation when needed?:

(Please answer yes, no, or explain circumstances. Leaving the space blank will delay the matching process.)

Referral Source

(leave blank if none applies)

Referring Agency or School:

Phone:

Name of person making referral:

Relationship to applicant:

Parent/Guardian/Emergency Contact Information

Parent(s) or Guardian(s):

Relationship:

Address and Phone:

Employer Name and Phone:

First emergency contact:

Phone:

Second emergency contact:

Phone:

Please describe the applicant’s needs as specifically as possible:

What are the applicant’s interests and hobbies? What kind of activities does s/he enjoy?:

(Please be specific.)

What are your reasons for referring this person for a volunteer?:

(Please list your specific concerns; medical, behavioral, etc.)

What characteristics/experience would the ideal volunteer have in relating to this particular applicant?:

How did you learn about the Community Friends Program? :

This applicant would prefer the volunteer be a:

Please feel free to include additional comments in this space:

Thank You!

Once the Community Friends program has received this application, the child will be put on a waiting list and eventually be matched with the most appropriate volunteer. Please be patient, as this takes time! Feel free to contact the office with questions at any time.

Email Address:

Community Friends Mentee Application Form

Community Friends

Alumnae receive Vermont Law School Scholarships

EIA Blogs

Say Cheese: LinkedIn Headshots

2013 Student Leadership Awards

Mentoring at Middlebury

Challenge Yourself!

If you're thinking about
applying to medical school,
here are the dates you
need to keep in mind.

2012 Scholarship Winners

Community Friends Mentee Application Form

Community Friends

Alumnae receive Vermont Law School Scholarships

EIA Blogs

Say Cheese: LinkedIn Headshots

2013 Student Leadership Awards

Mentoring at Middlebury

Challenge Yourself!

If you're thinking aboutapplying to medical school,here are the dates youneed to keep in mind.

2012 Scholarship Winners

If you're thinking about
applying to medical school,
here are the dates you
need to keep in mind.