Preview Mentor Application Form

Mentorship Program Application Form

If you would like to participate either as a mentor or mentee, please fill out the following form. Information will be

kept confidential and will only be shared with CPABC Executive.

Name: ______________________________________________

School: ______________________________________________

School Address: ______________________________________________ Email: ___________________

School Phone #: ______________________________________________ Cell: ___________________

Are you a CPABC member? � Yes No

Interest:

I want to be a mentor �

I want to be a mentee �

Please indicate learning goals you would have for this mentoring relationship:

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

Are you willing to commit to 1-2 hours every month for at least one year? �Yes� No

Is your school board or superintendent behind your commitment? �Yes� No

Are willing to travel to meet with mentor/mentee at least twice in a year? �Yes� No

Have you been a mentor or mentee (informally or in a program) before? �Yes� No

If yes, please describe your experience

Is there a mentee who you would prefer to be matched with?

HTML Preview Mentor Application Form page number 1.