Vermont Mentoring Database

Cabot Mentoring mentors serve as role models, active listeners and caring friends to youth living in Cabot. Mentors are matched with a child who shares similar interests, such as reading, cooking, computers, sports, gaming, hiking, fishing, and so on. Mentors and mentees commit to 1 year of meeting 2-4 times per month for an hour or two, and also have the opportunity to attend monthly group activities with other mentoring pairs from the Cabot community. Volunteers receive an initial 2 hour training, and ongoing twice-yearly training. This is a great opportunity to enrich the lives of 2 people at the same time! To find out more about Cabot Mentoring, or to apply to be a mentor, contact program coordinator at cabotmentoring@gmail.com.

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Basic Information

* First Name

Preferred Nickname or Salutation

Middle Name

* Last Name

Prefix	-- Select -- -- Select -- Mr. Mrs. Ms. Miss Dr. Honorable Prof.

Suffix	-- Select -- -- Select -- Jr. Sr. III IV.

Other names you have used (including maiden name)

Home Address

* Home Address Line 1

Home Address Line 2

* Home City

* Home State	-- Select -- -- Select -- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other

* Home State

Other (please specify)

* 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 1	Address 2	City	State	Zip
Previous Residence 1				-- Select -- -- Select -- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
Previous Residence 2				-- Select -- -- Select -- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
Previous Residence 3				-- Select -- -- Select -- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
Previous Residence 4				-- Select -- -- Select -- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
Previous Residence 5				-- Select -- -- Select -- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other

Employment Status

Other Employment Status

Current Job Title

Business Address

* Current Employer

Work Address Line 1

Work Address Line 2

Work City

Work State	-- Select -- -- Select -- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other

Work State

Other (please specify)

Work Zip code

Mailing Address

* Set mailing address

Home Address

Business 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 Name	Start Date	End 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

Yes

Website

Demographics

* Date of Birth

* Gender	-- Select -- -- Select -- Male Female Transgender Other Unspecified

Other (please specify)

* Ethnicity	-- Select -- -- Select -- African American/Black Asian Caucasian/White Hispanic/Latino Maori Middle Eastern Native American Pacific Islander Southeast Asian Other (please specify) Somalian Somali Bantu Congolese Rwandan Senegalese Dominican Bosnian Multi-Racial I'd Rather Not Say or Am Unsure

Other (please specify)

Marital status	-- Select -- -- Select -- Single Married

Education level	-- Select -- -- Select -- Some High School High School or GED Some College Associates Degree Bachelors Degree Masters Degree PhD Professional Degree

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

	Name	Age	Gender	Relationship
			-- Select -- -- Select -- Male Female Transgender Other Unspecified

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.

	Name	Phone	Email	Relationship	Length of Relationship
Reference 1
Reference 2
Reference 3
Reference 4
Reference 5

Application Information

* How did you hear about this program?	-- Select -- -- Select -- Event (please specify below) Facebook Ad Friend, Family Member or Colleague Instagram Ad MENTOR Vermont Website News Story Other (please specify below) Other Mentoring Agency (please specify below) Referred by MENTOR Vermont School (please specify below) Television PSA United Way: RSVP United Way: Volunteer Connection Website VPR Ad Web Search

* 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	-- Select -- -- Select -- Yes No

Please describe Disability and/or Additional Needs

Preferred School or Community	-- Select -- Cabot Mentoring

Other 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 some of your favorite subjects to read/learn about?

What are your personal goals?

If you could learn something new that isn't a current goal, what would it be?

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?

Yes

* Do you have a drivers license?

Yes

* Do you carry automobile insurance?

Yes

* Do you understand the commitment is for at least one year or school year?

Yes

If this program is not the right fit for you, would you be interested in learning about other mentoring opportunities in your area?

Yes

Additional Information

* Are there pending criminal charges against you?

Yes

* 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?

Yes

* Have you ever been arraigned for or convicted of child abuse or neglect or of sexually abusing or molesting a youth 18 or younger?

Yes

* Have you ever received treatment for alcohol or substance abuse?

Yes

* Have you ever been treated or hospitalized for an emotional/psychiatric condition?

Yes

* 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?

Yes

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.

* Last 4 Digits of Social Security Number

* 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	-- Select -- -- Select -- Male Female No preference

Availability

What are the best days of the week & times for you to mentor?

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Mornings
Afternoons
Evenings

Release Information

Media Release

The term ‘Agency’ is defined as the agency listed in the first field below.

Agency	Cabot Mentoring

* 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.

Yes

* I also agree to allow the Agency to grant permission, at its discretion, to MENTOR Vermont, 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.

Yes

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, national criminal records background check, the Vermont criminal conviction search, 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.	-- Select -- -- Select -- Yes No

National Criminal Records Check

Disclosure Regarding Volunteer Background Report

I understand that the Agency may obtain from Sterling Volunteers, 113 South College Avenue, Fort Collins, CO, 80524, (855) 326-1860. www.verifiedvolunteers.com, a report (“REPORT”) that contains background information about me in connection with volunteerism. Sterling Volunteers may obtain further reports throughout my volunteerism so as to update my report without providing further disclosure or obtaining additional consent.

The REPORT may contain information about my character, general reputation, personal characteristics and mode of living. The REPORT may include, but is not limited to, criminal and other public records and history and public court records, subject to any limitations imposed by applicable federal and state law. This information may be obtained from public record and private sources, including government agencies, judicial records, and other sources.

Authorization to Obtain Volunteer Background Report

I have read the above disclosure Regarding Volunteer Background Report and this Authorization to Obtain Volunteer Background Report. By checking the box below, I hereby consent to the preparation by Sterling Volunteers, a consumer reporting agency located at 113 South College Avenue, Fort Collins, CO, 80524, (855) 326-1860, www.sterlingvolunteers.com, of background reports regarding me and the release of such reports to the Agency and its designated representatives, to assist the Agency in making a volunteer decision involving me at any time after receipt of this authorization and throughout my volunteerism, to the extent permitted by law. To this end, I hereby authorize, without reservation, any state or federal law enforcement agency or court, educational institution, motor vehicle record agency, credit bureau or other information service bureau or data repository, to furnish any and all information regarding me to Sterling Volunteers and/or the Agency itself, and authorize Sterling Volunteers to provide such information to the Agency. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

* By checking this box, I grant permission for the Agency to obtain this report.

The Agency will not request a consumer credit report or credit history information. However, legally we are required to offer you the following document, "A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT." You can view and download this report by clicking here.

* By checking this box, I acknowledge receipt of a copy of the Consumer Financial Protection Bureau’s “A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT.”

* Date