What We Re Looking For

High School Program

Mentor Application

Would you like to support a young person with a disability in their transition from school to adult life? Are you interested in the arts, and becoming more engaged with your own community?

VSA Vermont is seeking adults with disabilities who are interested in becoming mentors for high school youth with disabilities. We have offered a structured classroom program to boost readiness for youth using the arts for over a decade, but we’re ready to take it a step further and bridge school and community with intergenerational creative connections.

What we’re looking for: - Adults with disabilities of any and all types, at least 22 years old - Interest in mentoring youth and providing a positive role model experience on an ongoing, volunteer basis - Interest in the arts – but no experience necessary, just a willingness to try new things! - Availability for in-school and community-based activities averaging one hour a week every week, typically during the school day, for the duration of at least one full school year - Local to either the Burlington or Barre/Montpelier area (for now: we hope to spread out over time) - Availability for two in-person training workshops: Saturday, August 8 1-5:00pm, and Friday, August 14, 9am-1:00pm. Site TBD.

We provide: - Training in mentoring, communication, and role modeling - Arts experiences of a variety of types in a variety of media and settings, including necessary materials and skill teaching, provided by local artists - Careful matchmaking and ongoing support for all mentor/mentee pairs - The chance to make a difference in the life of a young person with a disability at a critical time in their life If you’re interested in participating, please fill out the attached application form and return it to [email protected] or by mail to Toby MacNutt, VSA Vermont, 21 Carmichael St Suite 206, Essex Junction, VT 05452

www.vsavt.org twm 6/3/15 Mentoring Application, page 1/6 This program is made possible with the support of a large number of community partners, including: the Vermont Arts Council, Mobius Mentoring, Burlington City Arts, the Flynn Theatre, the Vermont Youth Orchestra, Lost Nation Theater, Aldrich Public Library, the Agency of Education, the Department of Vocational Rehabilitation, VABIR, and multiple high schools. MENTOR APPLICATION FORM Thank you for your interest in VSA Vermont’s high school mentoring program. We’re excited that you’re considering being a mentor! We’d like to know more about you.

Name: Address:

Email address: Phone number: home: cell: Age: Gender: Any other names:

How did you hear about our program?

What’s the best method to contact you?

Transportation: I have my own transportation I use public transportation and/or SSTA I do not have any independent transportation

Are you currently employed? Yes No If yes, employer’s information: Name: Position: Supervisor’s telephone number: Are you currently enrolled in college/university? Yes No

www.vsavt.org twm 6/3/15 Mentoring Application, page 2/6 If yes, where? What program?

Our mentoring model focuses on engagement with the arts. No arts experience is necessary! What artistic media have you used or would you like to try? (Check all that apply.) Have Would Type of Art Done Like to Try Beading and jewelry Clay and pottery Collage Costuming Dance (What kind?) Drawing (pencil, ink, charcoal, or other) Drumming Facepainting or other body art Glassblowing Graphic design and digital art Knitting or crochet Metalwork Musical instruments (which?) Painting Photography (digital or traditional) Poetry Sewing, quilting, and embroidery Scrapbooking Screenprinting Sculpture (mixed media) Singing Theatre (improv or rehearsed) Video Weaving

www.vsavt.org twm 6/3/15 Mentoring Application, page 3/6 Woodworking Writing (fiction or nonfiction) Why do you want to be a mentor?

What education, experience, or interests do you have that might be relevant to mentoring?

What are three things anybody who meets you should know about you? 1)

Please list three references, including no more than one family member. Name: Relationship: Address:

Phone: Email:

Name: Relationship: Address:

Phone: Email:

Name: Relationship: Address:

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Phone: Email: This program specifically matches adults with disabilities to youth with disabilities. While we don’t need to know what your disability is, we would like to know best to accommodate you, so that we can make sure to support our mentors and mentees appropriately. We do not discriminate against or in favor of particular disabilities or accommodations. “I need accommodations for…” (Check all that apply)

Mobility: moving around, Dexterity: doing tasks Communication: writing, standing or sitting with hands speaking, or sign

Information: reading, Other (please describe): learning, or understanding

I have a support worker who typically I use an ASL interpreter or another form of accompanies me human-assisted communication

“I would prefer to work with a mentee whose accommodations are…” similar to mine different from mine no preference

“I would prefer to work with a youth who is…” male female no preference

What are three ways you advocate for yourself or care for your personal well-being? 1)

What are the best days of the week and times for you to mentor? Place an “X” when available. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Mornings Afternoons

www.vsavt.org twm 6/3/15 Mentoring Application, page 5/6 Evenings

Have you ever been convicted of a crime? If yes, please explain:

Before a match can be made, all references must be returned and background check complete. Thank you for your interest in becoming a VSA VT mentor!

BY SIGNING BELOW, I ATTEST to the truthfulness of all information listed on this application.

I agree to let VSA Vermont confirm all information listed and to conduct reference checks and all permitted criminal records checks. I hereby AUTHORIZE VSA Vermont to request and obtain any and all records, documents and information about me from employers, agencies and references included on my application necessary for VSA Vermont to evaluate my suitability as a mentor. I understand that VSA Vermont will check some or all of the following: my records on the national sex offender registry, the Vermont child abuse and neglect registry, the Vermont criminal conviction search, FBI Fingerprint-based Background Check, and Vermont Motor Vehicles Driver Record Check. I hereby consent to the release of such records, documents, and information to VSA Vermont and to VSA Vermont’s designated representatives. I RELEASE and agree to defend and hold harmless from liability any person or organization that provides information.

I UNDERSTAND THAT this application is not a commitment or promise of a volunteer opportunity by VSA Vermont. I understand that it is in VSA Vermont’s discretion whether to accept me as a mentor and that VSA Vermont has no obligation to provide me with a reason for its decision to accept or reject me as a mentor.

I agree and acknowledge that this information may be disclosed by VSA Vermont staff to persons involved in the implementation of mentoring activities and programs. I hereby release and agree to defend and indemnify VSA Vermont, its directors, officers, partners, employees, affiliates, agents, successors, and its designated representative from any and all claims that may result from the use, release and disclosure of such information.

Signature: Date: If applicable: Legal guardian’s signature: Date:

www.vsavt.org twm 6/3/15 Mentoring Application, page 6/6 Please return by email to [email protected] or by postal mail to: Toby MacNutt, VSA Vermont, 21 Carmichael St Suite 206, Essex Junction, VT 05452. The deadline for the 2015-16 school year program is July 24 at 4pm.

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