Mentor Mentee Matching Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Race or Ethnicity
Gender
Please Select
Male
Female
N/A
Language Proficiencies
Address City Province
Email address Phone
Your Hobbies and Interests
Visual Arts
Electronic Games
Film Travel
Music
Volunteering
Politics
Reading (Fantasy/Fiction)
Sports
Literary Works
Other
What Best Describes you
Outgoing
Business-oriented
Constructive
Empathetic
Funny
Lively
Intuitive
Passionate
Reserved
Reflective
Vibrant
Other
Professional Interest or Expertise
Arts and Entertainment
Business and Development
Consultancy
Education
Engineering
Financial Services
Health Care and Medicine
Information Technology
Legal and Litigation
Marketing and Advertising
Non-Profit Administration
Politics
Publishing
Science and Technology
Other
The role you would like your Mentor would take part
Colleague
Nurturer
Listener
Teacher
Motivator
Career Development
Life Coach
Industry Coach
Other
Areas where you hope your mentor to make impact
Personality Development
Communication Skills Improvement
Self esteem & Developement
Other
Will this be your first time participating in a mentoring program?
Yes
No
Your Preference of Communication with your Mentor
email
chat
text
phone
in-person (might take longer to get paired)
Other
Your Preferred Mentor
Male
Female
How did you hear about us?
Social media
Website
Through a friend
Referral from community agency ( please specify)
Other
Will you be interested in joining our virtual support groups and programmes when available?
YES
NO
Other
Your Personal Information
Tell us something about yourself
Do you have any religious/personal beliefs, and if so, would you prefer to be paired with a mentor who shares those beliefs?
What are your expectations in this Mentoring program
What are your long and short term goals
What challenges are you currently facing?
Date
-
Month
-
Day
Year
Date
Submit
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