Mentee Referral Form: Community Friends
Community Friends is a program of the Middlebury College Center for Community Engagement. This is a college student-led program that matches Addison County youth aged 6-12 with college students for mentoring relationships that meet on a weekly basis during the academic year.

Submit this form by October 4, 2019 for a child to be considered for a mentoring match that would begin as early as the end of October. Forms submitted after the deadline will be considered for the wait list, potentially matched in early February 2020.

Questions? Contact Center for Community Engagement Assistant Director Kailee Brickner-McDonald at (802)-443-3010 or kbricknermcdonald@middlebury.edu
Part 1 of 4: Mentee and Parent/Guardian Information
Tell us about the child who wants a mentor!
Child's full name *
Your answer
Date of Birth *
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School the Child Attends
Your answer
Home Address(es) *
Your answer
Parent(s) or Guardian(s) Name(s) *
Your answer
Relationship(s) to Child
Your answer
Email (our preferred means of communication)
Your answer
Primary Phone *
Your answer
Alternative Phone
Your answer
Are either/both of the phone numbers listed cell phones that can receive text messages (if we don't successfully reach someone via email)?
Employer Name
Your answer
Part 2 of 4: Match Preferences
An important aspect of Community Friends is providing the opportunity for a child mentee to share similar identities and interests with their mentor, if desired. Please share your child's identities and interests that you would like us to keep in mind as we make mentor/mentee matches.
What's the child's gender identity?
Would you prefer to have the child's mentor share that gender identity?
What is the primary language spoken in the child's home? List other languages the child is comfortable speaking, if applicable. *
Your answer
If you prefer to have the child's mentor speak languages other than English with your child, please note that below by stating the preferred language(s).
Your answer
What is the child's racial identity?
Your answer
If the child identifies as a person of color, do they prefer them to have a mentor with a similar identity?
Are there other identities the child holds that you would like us to consider when making a mentor match? (Examples include: adopted, dis/ability, first in their families planning to attend college, religious identity, military family)
Your answer
What are the child's interests and hobbies? What kind of activities do they enjoy? Please be specific. *
Your answer
What are your reasons for referring this child to Community Friends? *
Your answer
Are there any specific concerns (behavioral, medical, etc.) we should know about? *
Your answer
What characteristics/experience would the ideal volunteer mentor have in relating to this child? *
Your answer
How did you learn about Community Friends? *
Your answer
Part 3 of 4: Referral Source
Leave this section blank if a parent/guardian is filling out this form.
Name of person making referral
Your answer
Relationship to applicant
Your answer
Referring Agency or School, if applicable
Your answer
Email
Your answer
Phone
Your answer
Part 4 of 4: Logistics
Submit this information if at all possible, as it will ease the match-making process. If the individual filling this out is not the parent/guardian, and can't be in touch with the parent/guardian to gather this information, please alert the parent/guardian to respond to the Community Friends program when we reach out to them for this information.
Can a parent or guardian provide transportation to weekly mentor meetings on Middlebury College's campus if needed? (Mentoring meetings are arranged with the mentor to work with the family's schedule.) *
Is there anything you'd like us to know about the parent/guardian's ability to provide transportation?
Your answer
First Emergency Contact Name and Phone Number (if the parent/guardian contacts provided above are unsuccessful)
Your answer
Second Emergency Contact Name and Phone Number (if the parent/guardian contacts provided above are unsuccessful)
Your answer
Indicate all Match Days (first match meeting, on Middlebury College campus) that the child and a parent or guardian can attend.
Thank you! We hope we can match this child with a mentor soon!
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