Wisconsin Braille Inc.
Braille
Directions: If you wish to
complete this form, you may do so by copying the entire document and pasting it
into an empty MS Word or Text document.
You can also print it out in order to complete the form. Once completed, mail the form either
electronically or via US mail to the project coordinators.
Name: ___________________________________________________
Address: ___________________________________________________
___________________________________________________
County: ___________________________________________________
Birthdate: _____________________ Social Security Number: ________________________
Home Phone #______________________________
Work Phone #_______________________________
Cell Phone #________________________________
Gender: _________
Ethnicity:
____________________ Primary
Language: ________________________
Other languages fluent
in:_________________________________________
Employer: ___________________________________________________
Employer Address:______________________________________________
___________________________________________________
Occupation: ___________________________________________________
Work Hours:
__________________________________
Length of Employment:
_________________
May we contact you at work? ________
Highest Level of Education: __________________________________________
Have you previously applied to be (or have you been) a
volunteer mentor? ________
If yes, where and
when? __________________________________________________________
Have you ever been involved before with Wisconsin
Braille, Inc.? ________
If yes, where and
when? __________________________________________________________
What, if any, other youth organizations have you
worked for or been involved with as a volunteer?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Wisconsin Braille Inc.
Mentoring Program Application
Page 2
Please type or print information requested for three references, which must include
people from the categories listed below:
1. Teacher
of the Visually Impaired, Wisconsin Braille Inc. board member, or other
individual who can speak to your braille skills:
Name & Relationship: ________________________________________________
Address: ________________________________________________
________________________________________________
Daytime Phone & Fax:
Email: ________________________________________________
2. Employer, professor, blindness professional:
Name & Relationship: ________________________________________________
Address: ________________________________________________
________________________________________________
Daytime Phone & Fax:
Email: ________________________________________________
3. Coworker/Friend/Neighbor who has known you
for at least two years:
Name & Relationship: ________________________________________________
Address: ________________________________________________
________________________________________________
Daytime Phone & Fax:
Email: ________________________________________________
Wisconsin Braille Inc.
Mentoring Program Application
Page 3
Please list below the places (city and state) in which
you have resided over the past 10 years. Your signature at the end of this
application will give us permission to conduct the background checks listed in
item 3 below.
YEARS
CITY
STATE
__________________ ________________________ __________________ __________________ ________________________
__________________ ________________________ __________________
__________________ ________________________ __________________
__________________ ________________________ __________________
__________________ ________________________ __________________
I understand that:
1. The references I listed may be contacted by
mail, telephone, or email;
2. I am in no way obligated to perform any volunteer
services;
3. The information I provided may be used to
conduct a background check, to include driving records check, criminal
background check, a child abuse registry check and other records where required
by local, state, or federal law for volunteers working with youth;
4. This organization is not obligated to match
me with a youth;
5. Other agencies or youth organizations where I
have worked or volunteered may be contacted as references; and,
6. As part of the enrollment process, including the
interview, I will be asked to provide additional personal information prior to
any recommendations for assignment.
________________________________________ ____________________________
Signature Date
Mail forms to:
Cheryl Orgas,
or