She Shadows: Mentor Experience

Mentor Application

Full Legal Name (First, Middle, and Last) *

Date of Birth *

Ethnicity *

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Cell Phone

Do you work remotely from home or work in an office? *

Home
Office
Both

Title: *

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Would you consider hosting a group of mentors and proteges at your worksite? *

Education Completed

High School
Certificate
College Graduate
Master's Degree
Other

How did you hear about She Shadows: Mentoring Experience? *

What motivated you to apply? *

Will you be able to meet with a protégé on a monthly basis during the duration of the mentorship program? *

What is your professional area of expertise and job responsibilities? *

What are your hobbies, special skills, or other interests? *

What other affiliations (e.g., service or volunteer organizations) do you have?

How will you contribute to the success of your protégé?

What do you hope to gain from the shadowing and mentoring experience?

What do you hope your mentee gains from the shadowing and mentoring experience?

Mentors often have a particular set of experiences to share, please help us achieve the best possible match by specifying if you would like to mentor a protégé from a specific cultural background (if available)?

If yes, what cultural background?

I certify that the information I have supplied is correct to the best of my knowledge. I grant permission for you to contact the references provided. I also understand and agree to the duties and requirements described in the Mentor Duties and Responsibilities.

Name *

First

Last

Phone

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