Mentor Enrollment Form

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VETERANS COURT STAFF

Jeffrey Thorne, Judge
La Porte County Superior Court 3

Eric LaRue, Case Mgr. La Porte County Probation Department

John Wilcher,
La Porte County Community Corrections

Deb Leroy, Director
La Porte County Drug & Alcohol Program

Joe Golec, Veterans Services Officer
La Porte County

Kurt R. Earnst, Deputy
La Porte County Public Defender’s Office

Luqretia Stuckey,
Veteran Justice Outreach Specialist

Barbra Stooksbury, Deputy Prosecutor
La Porte County

Katie Jasnieski, Swanson Center

Tyra Walker, Director of Treatment Services
La Porte County Jail

Brett Swanson,
LaPorte County Sheriff’s Department

EXTERNAL LINKS

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
La Porte County Superior Court 3
809 State Street, Suite 104A
La Porte, IN 46350

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

Download Enrollment Form

Fields marked with an ( ) are required*

Veterans Court

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home/Cell*
Work Phone*
Email*
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Availability
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 according to your daily availability.*
- Select All
- Weekday Mornings
- Weekday Afternoons
- Weekday Evenings
- Weekend Mornings
- Weekend Afternoons
- Weekend Evenings
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 according to your daily availability.
Military Service
Service Branch*
Active Duty Start*
MM slash DD slash YYYY
Active Duty End*
MM slash DD slash YYYY
Reserve Duty Start*
MM slash DD slash YYYY
Reserve Duty End*
MM slash DD slash YYYY
Type of Military Discharge*
Please note: In most cases, only veterans with Honorable or General Discharges will be considered for the mentoring program. If you received a General Discharge or other, please provide a few brief details pertaining to the discharge.
Explanation for discharge, if applicable.*
Grade Rank at Discharge*
Military Occupation Specialty*
(If you had more than one, please include all applicable)
Deployments*
Were you deployed during your time in active duty? 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 La Porte County Veterans Court Mentor Program?*
What type of civilian employment have you mainly worked since leaving the military, i.e. construction, administrative, sales.*
Other Skills and Qualifications
Special Skills or Qualifications*
Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.
Previous Volunteer Experience*
Summarize any previous volunteer experience.
Emergency Contact Info
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home/Cell*
Work Phone*
Email 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*
Month
Day
Year
Electronic Signature*
(First letter of your first name followed by last four digits of your 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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Mentor Enrollment Form

VETERANS COURT STAFF

Jeffrey Thorne, Judge La Porte County Superior Court 3

Eric LaRue, Case Mgr. La Porte County Probation Department

John Wilcher, La Porte County Community Corrections

Deb Leroy, Director La Porte County Drug & Alcohol Program

Joe Golec, Veterans Services Officer La Porte County

Kurt R. Earnst, Deputy La Porte County Public Defender’s Office

Luqretia Stuckey, Veteran Justice Outreach Specialist

Barbra Stooksbury, Deputy Prosecutor La Porte County

Katie Jasnieski, Swanson Center

Tyra Walker, Director of Treatment Services La Porte County Jail

Brett Swanson, LaPorte County Sheriff’s Department

EXTERNAL LINKS

MENTOR ONLINE APPLICATION FORM

Fields marked with an ( * ) are required

Veterans Court

Availability

Military Service

General Questions

Other Skills and Qualifications

Emergency Contact Info

Agreement and Electronic Signature

Our Policy