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Mentorship

Overview

 

Mentorship Faculty and Staff Application

Name
SalutationFirstMILast

State or Country of Birth:

Birth Date

MonthDay

School/College:

If you selected "Other" above, please enter your school here:

Department:

Campus Address

Building:Room:Zip Code:
Office Phone:
- -

Mailing Address (if different)

Address:

City:State:Zip Code:
-
Other Phone:
- -

E-mail Address

What is your preferred method of summer communication?
eMail
Phone
U.S. Mail

What is your affiliation with the University:
Faculty
Staff
Administrator

Position

Supervisor

What is your affiliation with the Mentorship Program:
New
Veteran

If you answered "Veteran", would you please indicate which year(s) you participated:

Is there a current upper-class student you would like to serve as a peer mentor with you?:

Academic Area And/Or Fields of Study: (Please choose one)

If you selected "Other" above, please enter your field here:

I am interested in mentoring students who are interested in one of the following pre-professional fields:

Extracurricular Interests (Please rank top three)

  Arts -
Visual		 Arts -
Performing		 Current
Events		 Community
Service		 Technology Recreational
Sports		 Lectures
and
Academia
First
Second
Third

Gender and Demographics:(both optional)
Male
Female

African-American/Black
Asian or Pacific Islander
Caucasian/White
Indian
Hispanic/Latino/a
American Indian or Alaskan Native
Other

Multiracial or Multi-Ethnic (specify):
International (specify):

What do you hope to give new students through a mentoring relationship?

What do you hope to gain from a mentoring relationship with new students?

How would you describe your mentoring style?

How much time and effort are you willing/able to commit to the mentoring relationship?