Mentee Referral Form: Community Friends

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Community Friends is a program of the Middlebury College Center for Community Engagement. It is a college student-led program that matches Addison County youth aged 6-12 with college students for 1-on-1 mentoring relationships that meet on a weekly basis during the academic year.

Submit this form to 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!).

Due to COVID-19 and Middlebury College policy, matches will meet primarily or completely remotely for the 2020-2021 school year.

Questions? Contact Community Friends Advisor Tenzin Dorjee at 802-443-5082 or tndorjee@middlebury.edu

Priority Deadline is Friday, October 8th 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 *

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)?

Yes, the primary phone number listed can recieve texts

Yes, the alternative phone listed can recieve texts

No, please don't text either number, even if you don't hear from me via email

Clear selection

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?

Boy

Girl

Gender Creative/Questioning

Other:

Clear selection

Would you prefer to have the child's mentor share that gender identity?

Must share that identity, please don't make a match unless they align (may delay the match)

Prefer that they share that identity, but don't require it

No preference for similar gender identity

Prefer that they do not share that identity

Other:

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?

Yes, we'd prefer that but not required

Yes, and please wait to match child until that preference can be met

No preference

Other:

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 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

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.

Will the mentee have access to technology and WiFi/internet either through a personal device or a school loaned device? *

Yes

Other:

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.)

Yes

Other:

Clear selection

Is there any tech support we can provide to help assist the mentees? In what ways, can we help make technical easier for you?

If your mentee is eligible to receive the vaccine and has done so they may be able to meet with their mentor in person. If you are comfortable please share that information below:

First Emergency Contact Name and Phone Number *

Second Emergency Contact Name and Phone Number (if the parent/guardian contacts provided above are unsuccessful)

Thank you! We hope we can match this child with a mentor soon!

If you have any questions, contact:

Shannon Lyford
Community Friends Advisor
slyford@middlebury.edu
802-443-5082

Maddie McKean '22
Community Friends Lead Student Coordinator
comfriends@middlebury.edu

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