REFORMA Mentoring Protege Application

MENTORING PROGRAM

MENTOR APPLICATION FORM
Please print form, fill it out and mail to the address below

NAME _______________________________________________________________________________
First Middle Last

HOME ADDRESS ______________________________________________________________________

_____________________________________________________________________________________
City State Zip Code Home Phone

PLACE OF EMPLOYMENT _______________________________________________________________
(IF APPLICABLE, INCLUDING PART-TIME)

ADDRESS _____________________________________________________________________________

City____________________________Zip Code__________________Work Phone_____________________

E-MAIL _______________________________________________________________________________

POSITION TITLE: __________________________________________________

Please list any special interests, areas of expertise, and leisure interests you could share with a Latino Protégé:

________________________________________________________________________________________

LANGUAGES:

Speak _________________________________________________________

Read _________________________________________________________

Understand _________________________________________________________

I WOULD LIKE A PROTÉGÉ: (Please check one)

I WOULD LIKE TO MENTOR A:

	Latino Spectrum Scholar
	REFORMA Scholarship Recipient
	Librarian. Please specify the type of library: _____________________________________________________

PREVIOUS PARTICIPATION:

	YES	NO
Have you ever served as a Mentor?
Have you ever been a Protégé

Are there other suggestions/concerns we need to pay attention to in matching your Protégé to you?

_________________________________________________________________________________________

If you belong to a REFORMA Chapter, please list the name of the Chapter

___________________________________________________________________________________________

COMMITMENT

I understand that to be involved in the REFORMA Mentoring Program I will have to commit to the following:

Commit to a two-year mentoring program

Commit to at least one contact per month.

Respond to an evaluation of the program.

Signed ______________________________________________________________________
(Applicant)

Please return application or direct inquiries to:

Alberto Herrera

Raynor Memorial Libraries

Marquette University

1355 W. Wisconsin Ave.

P.O. Box 3141

Milwaukee, WI 53201-3141

Tel: (414) 288-2140

Fax (414) 288-8821

email alberto.herrera@marquette.edu

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