Mentor Application

Thank you for your interest in serving as a mentor with Eileen & Callie’s Place. The following information is confidential and will only be shared with appropriate staff members. Please read all documents carefully before filling out or signing.  

Any questions regarding this application or other enclosed forms should be directed to Dr. Natalie Ellington, Executive Director, at 567.233.2632 or via email at eileenandcallie@gmail.com.
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Email *
Full name *
Address (street, city, state, zip) *
Phone numbers (cell, home, work) *
Email address *
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Person to notify in case of emergency
Emergency contact name *
Emergency contact address (street, city, state, zip)
Emergency contact phone (cell, home, work) *
Emergency contact email *
Emergency contact relationship *
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