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 Information

Name

First

Last

Phone

Email

Briefly describe any significant challenges you may have experienced, or are currently experiencing, that led you to apply for this program

0 of 5000 max characters.

In your own words, please explain how and why you are committed to moving forward in your life

0 of 5000 max characters.

How long have you been clean and sober? (N/A if not applicable)

0 of 255 max characters.

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)

0 of 5000 max characters.

Do you smoke? (For room assignment purposes only)

Is English your first language?

Please 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?

Please 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)

Would you allow us to contact the therapist or physician for support in your journey?

Why Not?

Physician or Therapist Contact Info

Layout

Are You Pregnant? (For shopping spree and graduation fitting of formals)

Due Date

Please communicate if there is a concern to participate in the overnight WorthShops or activities.

0 of 5000 max characters.

*** 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 herein

Release

I Affirm that this release and waiver shall be construed broadly to provide release and

Waiver of Liability for WoW

Waiver to the maximum extent permissible under applicable law

Room 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.

Mentee Application

Nomination/Application Form

WoW Utah Empowerment/Purpose & Life Skills Intention and Implementation – Two-day Retreat, January 19th - 20th

13th Annual Gala & Silent Auction Weekend – Three-day Event, November 15th-17th

Personal Information

Physician or Therapist Contact Info

Please include your first and last name, and email address.