TRIUMPH and SURGE Mentor Application

TRIUMPH/SURGE Mentor Application

* = required fields

TRIUMPH/SURGE Mentor Application

Mentor Program *

First Name *

M.I.

Last Name *

Address *

Apt#

City *

State *

Zip Code *

Phone Number (Preferred for contact) *

Email Address *

Racial Identity *

Employment Information

Employer *

Job Title *

Education Information

Highest level of education completed *

If applicable, list degree(s)

If applicable, list College(s)/Universities you have attended

Mentor Response

Please provide short responses to the following questions:

What motivated you to be a mentor for the TRIUMPH/SURGE program? *

Will you be able to engage with a student at least once a week during the school year? *

What day(s) of the week are you available for potential mentor workshops? (check all that apply) * Monday Tuesday Wednesday Thursday Friday

What are your hobbies/special skills? *

What are your other Interests? *

What other affiliations/volunteer organizations are you involved with? *

What do you hope to gain from the mentoring experience? *

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

Do you have prior mentor experience? *

If yes, please list (program name & dates)

How was the TRIUMPH/SURGE program brought to your attention? *

Electronic Signature Verification

I certify that the information I have supplied is correct to the best of my knowledge. I also understand and agree to being a TRIUMPH/SURGE mentor in the TRIUMPH/SURGE program.

Verification Confirmation *(represents electronic signature)

Verification Date * (mm/dd/yyyy)

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TRIUMPH and SURGE Mentor Application

TRIUMPH/SURGE Mentor Application