Mentee ApplicationPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Nomination/Application Form By submitting this Application for the WoW Utah Mentee Program, You are commiting yourself to the following dates: WoW Utah Empowerment/Purpose & Life Skills Intention and Implementation – Two-day Retreat, January 19th - 20th ***(DATES MAY BE SUBJECT TO CHANGE*** *** ALL DATES WILL BE CONFIRMED BEFORE ACCEPTANCE OF THIS APPLICATION. *** (These dates are in ADDITION to meeting monthly and weekly check-ins with your mentor.) Jan. 19th - Day One Jan. 20th - Day Two Before Photos – All Women of Worth participants receive a sweatshirt to wear. However, please dress comfortably Ah Ha moments Welcome and Grounding Journaling and moving forward Life skills training Reflection time – Gratitude Goals and commitments Panel of courageous women of worth Lunch / Dinner Lunch Meet and greet with mentors Mentors and Mentee time Guest Speaker – Evening session Additional Dates of Commitments ****WorthShop’s content is subject to change***** February 10th July 13th March 9th August 10th April 12th-13th September 14th May 11th October 12th June 8th November 15th-16th (Gala and Silent Auction Event) **Hotel Accommodations & Food will be provided. ***** Must be able to stay overnight on required two-day WorthShops. Arrangements must be made for childcare and pet care. 13th Annual Gala & Silent Auction Weekend – Three-day Event, November 15th-17th Nov. 15th - Day One Nov. 16th - Day Two Full day of reflection, guest speakers, and where we are and where we are going. Makeover – Haircuts and Makeup makeovers. Manicures/Pedicures in the evening. Dress for Gala Event. Catered dinner. After photos. Entertainment. Awards Ceremony and Recognition Over Night Hotel Stay for two nights: Friday to Sunday Morning **Hotel accommodations & food will be provided Personal InformationName *FirstLastPhoneEmail *Briefly describe any significant challenges you may have experienced, or are currently experiencing, that led you to apply for this programIn your own words, please explain how and why you are committed to moving forward in your lifeHow long have you been clean and sober? (N/A if not applicable) Are you, or have you ever been impacted by domestic violence or polygamy? If yes, please explain in your own words. (N/A if not applicable)Do you smoke? (For room assignment purposes only) *YesYesNoIs English your first language? *YesYesNoPlease explain here (For Mentor pairing and materials)Please list any medical conditions, food or other allergies that we need to be made aware of. *Are you currently taking any medications for a medical condition? *YesYesNoPlease List them here *Are you currently under a therapist's or physician's care? (you must supply a letter of clearance to participate in the program) *YesYesNoWould you allow us to contact the therapist or physician for support in your journey? *YesYesNoWhy Not? *Physician or Therapist Contact Info LayoutName *FirstLastPhone *EmailAre You Pregnant? (For shopping spree and graduation fitting of formals) *YesYesNoDue Date *Please communicate if there is a concern to participate in the overnight WorthShops or activities.*** Each applicant or nominee is required to have an interview in person prior to acceptance into the program. *** Interview Process *I understand I will not be accepted into the program until I have had an interview in person.Full Waiver Clause *I hereby (A) waive, release, and discharge from any and all liability for the death, disability, personal injury, property damage, property theft or actions of any kind including and not limited to emotional or psychological effects which may hereafter accrue to me or my organization/business* named above (if applicable), WoW Utah and its representatives, officers, agents, and employees (B) indemnify and hold harmless WoW UTAH and its representatives, officers, agents, and employees from any and all liabilities and claims made by other individuals or entities as a result of any of my actions or the actions of any representative, participant, or an agent, employee, or member of my organization/business* named above (if applicable) I hereby agree while being involved in this two-day event, I will abstain from any drugs’ alcohol or any other mind-altering substances.Acknowledge *I Acknowledge that I have read and understand the waiver and release described hereinRelease *I Affirm that this release and waiver shall be construed broadly to provide release andWaiver of Liability for WoW *Waiver to the maximum extent permissible under applicable lawRoom Ackowledgment *I am aware the only person(s) to be in my hotel room at any time is my WOW roommate, other women of worth, or WOW Utah staff. I also understand that I may not leave the premises of the hotel until the program of the 2 (two) days have concluded unless given permission.Scheduling Commitment *I commit to a once-a-month WorthShop, meetings in person with my mentor, and monthly check-ins by email and by phone with my mentor. Not adhering to these commitments could warrant removal from the program.Time Respect *I fully commit to be in touch with, and respect the time(s) set up with myself and my mentor. Should I have to cancel I will call or text to reschedule another time and date. I will commit to connecting and staying in contact with my mentor per the guidelines of this program. I will attend all the dates of commitment for the WorthShops and meet with my mentor.Not adhering to any of these stipulations or not committing to the agreed WorthShops or mentee meetings in this agreement may warrant immediate removal from the WoW Utah program. Submit
