& Me Summer Mentor Registration
Program Duration: June 20 – September 22, 2025 | Mentoring Format: Virtual & Flexible Participation | Thank you for your interest in becoming a mentor for the & Me Mentorship Program! Please complete the form below, and we’ll follow up with you soon.
Personal Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
City
State / Province
Postal / Zip Code
Professional & Mentoring Experience
What is your current profession/role?
What industries or fields do you have experience in?
Have you mentored before? (Check all that apply)
Yes, formally (coaching, leadership programs, etc)
Yes, informally (guiding peers, friends, etc)
No, but I’m excited to start!
What topics are you most passionate about mentoring in? (Check all that apply)
Confidence & Self-Worth
Resilience & Overcoming Setbacks
Career Development & Leadership
Public Speaking & Communication
Personal Growth & Goal-Setting
Business & Entrepreneurship
Other
Availability & Preferences
How much time can you commit to mentoring this summer?
1-2 hours per week
3-5 hours per week
Flexible, depending on need
Preferred mentoring format:
In-Person (add how far you’re willing to travel in “other” space)
Virtual
Both
Other
Preferred communication method
Phone/Video calls
Text messages/Telegram
Email
Other
Personal Motivation & Impact
Why do you want to be a mentor in this program?
What qualities or experiences make you a great mentor?
If you’ve never been a mentor before, what qualities or experiences do you think will make you a great mentor?
What are you looking for in a mentee?
Media Consent
Do you give permission for photos or video recordings of you to be taken during program events, mentorship sessions, or activities for use in the & Me’s promotional materials (such as flyers, social media, website, or highlight videos)?
Yes, I give permission for my image to be used for promotional purposes.
No, I do not give permission for my image to be used.
Final Confirmation
Are you able to commit to the full program duration (June 20–Sept 22, 2025)? *Here is where you let us know when you can start & need to finish
Yes
No (Please explain in “other”)
Other
Would you like to be considered for future mentoring opportunities? Our 1st full semester session starts soon!
Yes
No
Other
Next Steps
By submitting this form, you agree to maintain professionalism, confidentiality, & a supportive mentorship approach. After submission, we will review your application. Once selected, mentors will receive onboarding materials and be paired with mentees before the program starts.
Submit
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