Griffin Mentoring: James River Elementary Mentee Application

Thank you for your interest in Griffin Mentoring, a partnership between W&M's Office of Community Engagement and James River Elementary! Each student selected for participation will be matched with a W&M mentor for the 2017-18 academic year. Pairs will meet for 45 minutes each week during lunch and recess from late September – April (while W&M classes are in session). Mentoring will take place during the school day and will not interrupt instruction. All mentors are screened through an application and interview process, which includes a sex offender registry check.

How does mentoring help? Research from the Search Institute and other youth development experts shows that having multiple close relationships with caring adults helps young people:

  • become actively engaged in their schools and communities
  • form positive relationships with peers, teachers, and family members
  • value school and feel like they belong
  • develop strong academic motivation and success

Applications are due by Thursday, September 14. Applicants will be informed by late September whether they have been accepted into the program.

Questions? Please contact Ms. Smith, JRE school counselor, or Mary Kate Maher, JRE Griffin Mentoring school coordinator.

Student Information

*2017-18 Grade

Note: For this year, Griffin Mentoring is only open to JRE 2nd and 3rd graders. We hope to expand in future years.

Parent/Guardian #1
Parent/Guardian #2
Member(s) of Child's Household
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Parent/Guardian Survey

The following questions will help us get to know your child and match them appropriately with a mentee.

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Parent/Guardian Consent Form

Please review and enter your initials next to each item.

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Participant Agreement

In consideration of my acceptance to engage in Griffin Mentoring programming from September 2017 to May 2018 at the College of William & Mary, I do hereby release The College of William & Mary, its officers, directors, employees, and agents (“the College”) and Griffin Mentoring and all programs of the Office of Community Engagement and its members (“the organization”) from responsibility for:

  1. Any and all injuries caused by the negligence, recklessness, or intentional acts of myself and/or any third parties.
  2. Any and all property damage that may occur while I participate in Griffin Mentoring. My property damage waiver includes all property damage, including that caused by the negligence, recklessness, or intentional acts of myself, third parties, the College, and/or the organization.

I hereby acknowledge that my (or my child’s) participation is strictly voluntary, and that by signing this document I knowingly assume all risks associated with my (or my child’s) participation in Griffin Mentoring. I agree to stop and request assistance if I (or my child) experience any symptoms such as, but not limited to, dizziness, excessive fatigue, shortness of breath, pain, or any other conditions which would make it difficult or unsafe to continue. I (or my child) further agree to obey all federal, state, and local laws; use proper safety equipment when applicable, including seatbelts in moving vehicles; and follow the instructions of the Griffin Mentoring coordinators while participating in this event.

Assumption of Risk: I fully appreciate the nature and extent of the risks involved in Griffin Mentoring. Participation in a Griffin Mentoring event carries with it certain inherent risks that cannot be eliminated regardless of the care taken. These risks include, but are not limited to: 

  • Accidents related to transportation, including collisions with motor vehicles and careless drivers or vehicle failure, and injuries including death resulting therefrom.  
  • Cuts, scrapes, bruises, concussions, and musculoskeletal injuries resulting from horseplay, participation in games, or tripping or falling on uneven surfaces.
  • Injuries and illness resulting from the effects of weather, including high heat or cold temperatures, high winds, humidity, and precipitation
  • Food poisoning or choking

Representations Concerning Health: With full knowledge of the risks inherent to Griffin Mentoring, I represent that I (or my child) am in good health and do not have any condition which will interfere with my (or my child’s) ability to participate in Griffin Mentoring or endanger my (or my child’s) health in connection with Griffin Mentoring. I acknowledge valid and current insurance to cover any injury or damage I (or my child) may cause or suffer while participating in the Griffin Mentoring or otherwise agree to personally bear the costs of such injury or damage. I authorize, but do not obligate, an Office of Community Engagement representative to seek emergency medical treatment for me (or my child) in the event of an accident or illness that occurs during my (or my child’s) participation in the Griffin Mentoring, even in the event that I (or my child) am unconscious or otherwise cannot consent. I attest that if I (or my child) have recently suffered an illness, injury, or impairment, or have any concerns about my (or my child’s) ability to participate in the Griffin Mentoring, I should have or did consult a physician prior to my participation. I further take full responsibility for consulting a physician if I experience any doubt as to my (or my child’s) ability to successfully and safely complete the Griffin Mentoring event once it has begun.

*Photo Release: (Please check one)

Mentee Survey

The following questions should be answered by the student with support from a parent/guardian.

*What are your favorite academic subjects? Check all that apply.

*What activities do you enjoy?

*What topics do you enjoy reading, learning, or talking about?

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Please type the following word (no spaces) into the box provided.

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