Personal Information

Name: ______

Address: ______

Phone No: ______Fax No: ______

Top of Form

Email Address: ______Gender:  Male Female

Best Contact Method and Information (check one): ____ email ____cell _____ text

Best Time to Contact:

Mentoring Program Preferences

Please indicate the area(s) in which you are able to mentor. Check all that apply:

 Sciences  Technology  Engineering  Math

Please list specific interests: ______

When would you prefer to meet with your mentee? Check all that apply:

 Weekday Mornings  Weekday Afternoons  Weekday Evenings

 Weekend Mornings  Weekend Afternoons  Weekend Evenings

What is your preference to meet/ communicate with your mentee? Check all that apply:

 Face to Face Email  Phone Virtual (i.e., Facebook, Chat room)

Are you interested in mentoring Check all that apply:

 High School Students  4-year Undergraduate Students  Community College Students

 Graduate Students  A Working Individual

Do you prefer to mentor:

 Individual Student  A Group of Students  Both

Have you been a mentor before?  Yes  No

If yes, please explain in what capacity and how long:______

______

______

What skills do you bring to mentoring:______

Additional Forms Please submit the following items, along with this completed application form.

 Curriculum Vitae (CV) or Resume______

Informed Consent

Please read carefully before signing.

  • I understand that the mentoring program involves checking in with the mentor(s) at least 2 times per week.
  • I understand that I will be required to fill out mentoring documentation on a monthly basis in order to receive payment.
  • I understand that I will be required to complete the Pacific Alliance Mentor Program Orientation and at least one Professional Development training session before I start my mentoring (time is compensated).
  • I understand that I will be required to participate in on-going training offered on a regular basis. If I am unable to attend sessions, I am responsible in notifying the Mentor Coordinator at least 3 days before the training and am responsible in making up the missed session within a time agreed upon with the Mentor Coordinator.
  • I certify that the facts contained in this application are true and complete to the best of my knowledge.

______Signature______Date

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