West Hartford Public Schools

Mentor Program
Application
 

 

Please fill out all information on this form.  After filling out this form click on the submit button at the end of this document.  This will automatically send your request to the WHPS District Mentor Coordinator.

 

If you are unable to register through this process or if you have any questions, you may contact Carol Wilkas at 231-6079 or e-mail her at  MentorProgram@whps.org.  You may also print out the form and send it to: 110 Beechwood  Road, West Hartford, CT 06107  ATTN: Carol Wilkas

 

 

MENTOR APPLICATION

PERSONAL INFORMATION

Last Name:   First Name:

Address: 
Street Number: Street Name: (Apt, P.O.Box, Room Number)
Town: Zip Code:

Telephone: Area Code: Phone number
 

Date of Birth: Age:   Sex:

 

Home Email Address:


Emergency Contact:   Telephone:

Please describe any medical issues that might limit your participation in this program:


EMPLOYMENT INFORMATION

Employer Name:

Address: 
Street Number: Street Name: (Apt, P.O.Box, Room Number)
Town: Zip Code:

Telephone: Area Code: Phone number
Fax: Area Code: Phone number

Work Email Address:

Please highlight the responsibilities within your position:




MENTORING INFORMATION

Day(s) and Time(s) you are available to mentor:


Grade Preference:
Elementary (K-5)  Middle School (6-8)  High School (9-12)  No Preference

Would you like to mentor a: female male

List your experiences (either professional or volunteer) working with students K–12:


Why are you interested in becoming a mentor?


REFERENCE REQUEST

Please provide three references other than a relative:

1. Last Name:   First Name:

Address: 
Street Number: Street Name: (Apt, P.O.Box, Room Number)
Town: Zip Code:

Telephone: Area Code: Phone number

No. of years acquainted


2. Last Name:   First Name:

Address: 
Street Number: Street Name: (Apt, P.O.Box, Room Number)
Town: Zip Code:

Telephone: Area Code: Phone number

No. of years acquainted


3. Last Name:   First Name:

Address: 
Street Number: Street Name: (Apt, P.O.Box, Room Number)
Town: Zip Code:

Telephone: Area Code: Phone number

No. of years acquainted



ACKNOWLEDGEMENT

I understand that the West Hartford Public Schools Mentor Program involves spending approximately one hour each week from September to June at an assigned school with my mentee. I will be committing to one school year in the program and will then be asked to renew for another year. I have not been convicted, within the past ten years, of any felony or misdemeanor classified as an offense against a person or family, of public indecency, or a violation involving a state or federally controlled substance. I am not under current indictment. Further, I hereby fully discharge the school personnel, participating companies, or organizations from any liability, claims, causes of action, costs and expenses which may be attributable to my participation in the West Hartford Public Schools Mentoring program.

I understand that the West Hartford Public Schools Mentor Program and relationships established take place during the confines of the school day in West Hartford, CT. It is not part of any relationship established between mentor/mentee and family members beyond the school day. I also understand that any photographs and/or video taken during the mentoring sessions become the property of WHPS and may be included in promotional materials.

I have read the above release statement and agree to its content. To the best of my knowledge and belief, all statements in the application are true.
If you agree that the information in this application is correct, click here and enter the date: