Mentor Online Application Form

If you would like you can download and print out the form below and mail it to the following:

Veterans Treatment Court
c/o Agnes Meer Project Coordinator
LaPorte County Superior Court 3
809 State Street, Suit 104A
LaPorte, IN 46350

Download the Enrollment Form Here

Fill out the online form below. No information is saved.

Fields marked with an * are required

General Information
Name *
Address *
City State ZIP Code *
Home/Cell *
Work Phone *
E-mail Address *
Date of Birth *
Social Security Number *
Availability
Serving as a mentor will require you to attend court proceedings and to meet regularly with your mentee as they proceed through the Veterans Court program which can last 12-18 months. Although our goal is to have a back-up mentor for all veterans in the program, serving as a mentor will require you to attend court proceedings with your mentee during weekday business hours.

Mentors will also be expected to attend training sessions, mentor meetings, shadowing sessions, and observational sessions.

During which hours are you available for mentoring assignments? (Please note, availability is not only for in person meetings but also phone communications with mentee). Please mark each time frame with either an A for Always or Usually, a S for Sometimes, or a R for Rarely or Not Available.
Weekday Mornings * Weekend Mornings *
Weekday Afternoons * Weekend Afternoons *
Weekday Evenings * Weekend Evenings *
Military Service
Service Branch *
Please list Dates of Service for all that apply *
Active Duty Start
Active Duty End
Reserve Start
Reserve End
Type of Discharge (Please note in most cases only veterans with Honorable Discharges will be considered for the mentoring program. If you received a General Discharge, please provide a brief statement explaining the reason(s) for it.
*
Explanation for General Discharge, if applicable.
Rank at Discharge *
Military Occupation Specialty (MOS) (If you had more than one, please include) *
Deployments *
Were you deployed during your time in service? If so please list all deployments and approximate dates.
Veterans Affairs
Did you or do you receive services from the US Department of Veterans Affairs? *
General Questions
Why did you leave the military? *
Why do you want to become a Veterans Court Mentor? *
What are you hoping to gain by becoming a mentor in the LaPorte County Veterans Court Mentor Program? *
What type of civilian employment have you mainly worked since leaving the military, i.e. construction, administrative, sales. *
Special Skills or Qualifications
Summarize special skills and qualification you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports. *
Previous Volunteer Experience
Summarize any previous volunteer experience. *
Person to Notify in Case of Emergency
Name *
Address *
City ST ZIP Code *
Home/Cell *
Work Phone *
E-mail Address *
Agreement and Electronic Signature
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a mentor, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. Additionally, by submitting this application I understand I am consenting to a criminal background check. (Please note, individuals with felony convictions, any convictions for crimes of violence or individuals with any pending criminal cases will not be eligible to serve as a mentor). All information will be kept strictly confidential.
Full Name *
Date *
Electronic Signature *
(First letter of your first name followed by the last 4 of you SSN)
Our Policy
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual orientation, age, or disability.

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