MENTOR APPLICATION

To mentor a UCSC Collegiate Fellow, fill out this form. If you are interested in mentoring a Cabrillo College student or local high school student, contact Bill Dickinson, 617-671-8009, or by e-mail.

 
Your First Name M.I. Your Last Name
Street Address
City County State ZIP
Preferred Email Secondary Email
Home Phone (Area code) xxx-xxxx Work Phone (Area code) xxx-xxxx Cell Phone (Area code) xxx-xxxx Fax Number (Area code) xxx-xxxx

UCSC Affiliation

If you are a UCSC alumna or alumnus:
College Grad Year Major/Minor

Other college interests?


What type of volunteer activities have you previously been involved in?


Would you be interested in assisting a student in solving problems they might be having with the university bureaucracy ?

Current Vocation Current Employer

Would you be willing to offer a student career advice?


What are your avocations?


Would you be willing to include a student in your avocation activities?


What type of relationship would you like to have with a student? Short-term
Long-term


Do you have a specific project or subject area on which you would like to work with a student?



Would you want to communicate with a student via email?
Yes
No
Would you want to communicate with a student via telephone?
Yes
No
Would you want to communicate with a student via U.S. mail?
Yes
No

Would you be willing to help a student locate services they might need in the community?
Yes
No

Would you be willing to provide vacation and holiday support to a student by:

Inviting a student to dinner?
Yes
No

Providing a place to stay overnight?
Yes
No

Including a student in your holiday celebrations?
Yes
No

Storing a student's belongings over the summer?
Yes
No

Providing rides to or from the airport?
Yes
No

Would you prefer to mentor:
Female
Male
No preference

Is there anything else that would be helpful for us to know about you to assist us in pairing you with a student?


Which of the following aspects of mentoring most interest you: (please respond by ranking each choice 1, 2, or 3 with 1 indicating the greatest interest)

Offering academic support, guidance, tutoring, and advice on courses.
1 2 3
Providing general life support like a place to stay during vacations, transportation to and from airports, storing belongings during the summer, etc.
1 2 3
Offering moral support and encouragement.
1 2 3