/ Vets 4 Vets
Veteran Mentor Program

Student (Mentee) Application

Thank you for completing this application for the Lord Fairfax Community College Veteran Mentor Progam. Please return this application to Veterans Services by e-mail, mail, or in person using the contact information below. Submitting your application expresses your interest in being matched with a mentor for one academic year. Please know that the LFCC Veteran Mentor Program will keep all the information on this application in confidence and will use it solely for purposes of this program.
Sandy Burner
Veterans Specialist
540-868-7088
540-868-4134 (fax)
/ Middletown Campus
173 Skirmisher Lane
Middletown, VA 22645 / Fauquier Campus
6480 College Street
Warrenton, VA 20187

Applicant Information

Full Name: /
Preferred name:

Last

/

First

/

M.I.

Gender: /

Date of Birth:

Ethnicity: /

Emergency Contact Name:

Emergency Contact phone: /

Emergency Contact Relationship:

Address:

Street Address

/

Apartment/Unit #

City

/

State

/

ZIP Code

Home/Mobile phone: /
E-mail:
Employer Name (if applicable):
Employer Address:

Street Address

/

Ste #

City

/

State

/

ZIP Code

Work phone: /

Occupation:

E-mail address:
Preferred mode of contact? /

E-mail Home/Mobile phone Work phone Other :

Specify

Military Service

Branch: /
From:
/
To:
Rank at Discharge: /
Type of Discharge:

Background

Have you ever been convicted of a felony? / YES / NO
Within the last 10 years have you been convicted of a misdemeanor classified as an offense against a person or family, or an offense of public indecency or a violation involving a state/federally controlled substance?
/ YES / NO
Are you under current indictment or has a district/county attorney accepted an official complaint for
any of the offenses in the previous two questions? / YES / NO
If yes to the above questions, please explain:

Past Education (complete any that apply to you)

High School: /
City, State:
From: /
To:
/
Did you graduate?
/ YES / NO /
Diploma:
College: /
City, State:
From: /
To:
/
Did you graduate?
/ YES / NO /
Degree:
Other: /
City, State:
From: /
To:
/

Did you graduate?

/ YES / NO /

Degree:

Application Questions

  1. What are your expectations of the Veterans Mentor Program?
  1. Write a brief statement on why you have chosen to participate in the Veterans Mentor program at LFCC.
  1. What are a few of your favorite books or movies?
  1. What clubs or groups, if any, do you belong to?
  1. What qualities would you like in a mentor you are matched with?
  1. What are your plans for after you complete your program at LFCC?
  1. Are you currently having any problems either at home, work or school? If yes, please give a brief explanation or description.
  1. What are a few things about yourself that you would like your mentor to know?
  1. Please check off the activities you enjoy the most from the list below:

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Playing sports such as:

Watching sports such as:

Writing

Reading

Listening to music such as:

Photography

Attending plays

Going to the movies

Arts and crafts

Visiting zoos and parks

Visiting museums

Using computers

Playing games such as:

Cooking

Exploring possible careers

Hiking and seeing nature

Fishing and/or hunting

Attending community events such as:

Other:

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Medical History

Do you have any health conditions or limitations, either physical or mental/emotional?

Are you currently receiving treatment for any health issues?

Is there any other health concern your mentor should know?

Scheduling and Matching

Are you available to meet with a mentor four hours per month and have contact at least once a week for a full academic year? Yes No

Do you have a car? Yes No

Do you currently work? Yes No

If yes, how many hours per week?

Please describe your current work and class schedule:

Which days of the week are you available to meet with a mentor? (check all that apply):

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

What is the best time of day for you to meet? (check all that apply):

Mornings Afternoons Evenings Weekends Other (Please specify):

Do you prefer working with a Male Female No Preference

Do you prefer working with a student from a specific racial/ethnic group? Yes No

If yes, please specify:

Do you speak any foreign languages? Yes No

If yes, please specify:

Disclaimer and Signature

Please initial each of the following statements.

____ I certify that my answers are true and complete to the best of my knowledge. I understand that misinformation knowingly provided here, and on subsequent mentor application forms, is grounds for dismissal.

____ I understand that the mentor program involves spending time and/or some type of contact with mentor each week for the length of the match with an assigned mentor (time spend needs to in person during initial part of program).

____ I understand that I will be required to complete the mentor program orientation and at least two training sessions during the year.

____ In making this application to be matched with a mentor, I understand that the Veterans Mentor program routinely performs criminal and driving record checks of all applicants. This check may be done on me if I sign below. If I fail to sign, it may be grounds for rejecting me from the program.

____ I agree to follow all mentoring program guidelines and understand that any violation on my part may result in suspension and/or termination of the mentoring relationship.

____ I release the Veterans Mentor Program of all liability of injury, death, or other damages to me, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Veterans Mentor Program mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

____ I agree to communicate openly with program staff and receive feedback during my participation in this program.

Signature: /

Date:

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