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MENTORING PROGRAM |
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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)
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Male |
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| Female | |
| No Preference |
I WOULD LIKE TO MENTOR A:
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Latino Spectrum Scholar |
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REFORMA Scholarship Recipient |
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Librarian. Please specify the type of library: _____________________________________________________ |
PREVIOUS PARTICIPATION:
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YES
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NO
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Have
you ever served as a Mentor?
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Have
you ever been a Protégé
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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:
Homepage | Mentoring Program | Protégé Application | Mentor Application