Please complete this form if you would like to participate in the Leadership Mentoring Program as a Mentor. After submission of this form, you will be contacted within a reasonable amount of time as to your acceptance in the program.

Please ensure that you are available to attend all 7 required synchronous (multimodal, in-person) peer learning session dates.

Please note that the number of participants in the program will be dictated by the ability to match all mentees with mentors.

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* 1. Name

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* 2. Email

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* 3. Department/School

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* 4. Current Position

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* 5. Consideration for Selection. Please check all applicable boxes:

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* 6. Information to Facilitate the Matching Process: Based on the 5 leadership strengths in the College's, Leadership Requirements Model, which of these 5 strengths will you bring to the mentoring partnership? Please list all that apply:

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* 7. Information to Facilitate the Matching Process: What goals do you hope to achieve by participating in this program?

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* 8. Information to Facilitate the Matching Process: Other information you would like to share that would help in the matching process.

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* 9. My direct supervisor supports my interest in being involved in this program & I am available to attend all 7 required synchronous (multimodal, in-person) peer learning session dates.

Please note, your application cannot be accepted unless you respond "yes."

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