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 and be added to the waitlist for when a mentor becomes available (we match most mentors and mentees in the fall, but also make pairings in late January and early February, too!).

Questions? Contact Center for Community Engagement Assistant Director Kailee Brickner-McDonald at (802)-443-3010 or kbricknermcdonald@middlebury.edu
This form is due October 2nd at Midnight
Part 1 of 4: Mentee and Parent/Guardian Information
Tell us about the child who wants a mentor!
Child's full name *
Date of Birth *
MM
/
DD
/
YYYY
School the Child Attends
Home Address(es) *
Parent(s) or Guardian(s) Name(s) *
Relationship(s) to Child
Email (our preferred means of communication)
Primary Phone *
Alternative Phone
Are either/both of the phone numbers listed cell phones that can receive text messages (if we don't successfully reach someone via email)?
Clear selection
Employer Name
Part 2 of 5: 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?
Clear selection
Would you prefer to have the child's mentor share that gender identity?
Clear selection
What is the primary language spoken in the child's home? List other languages the child is comfortable speaking, if applicable. *
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).
What is the child's racial identity?
If the child identifies as a person of color, do they prefer them to have a mentor with a similar identity?
Clear selection
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)
What are the child's interests and hobbies? What kind of activities do they enjoy? Please be specific. *
What are your reasons for referring this child to Community Friends? *
Are there any specific concerns (behavioral, medical, etc.) we should know about? *
What characteristics/experience would the ideal volunteer mentor have in relating to this child? *
How did you learn about Community Friends? *
Part 3 of 5: Technology Access and preferences
Will the child have access to technology and WiFi/internet either through a personal device or a school loaned device? *
If virtual mentoring is not possible for you, would you be interested in participating in mentorship in other ways? (ex. letter writing, phone calls, etc.) *
Part 3 of 4: Referral Source
Leave this section blank if a parent/guardian is filling out this form.
Name of person making referral
Relationship to applicant
Referring Agency or School, if applicable
Email
Phone
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?
First Emergency Contact Name and Phone Number (if the parent/guardian contacts provided above are unsuccessful)
Second Emergency Contact Name and Phone Number (if the parent/guardian contacts provided above are unsuccessful)
***If you are applying in the fall of 2020 only*** 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!
Submit
Never submit passwords through Google Forms.
This form was created inside of Middlebury. Report Abuse