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MENTORSHPE REGISTRATION
Complete the form below to be included in our MentorSHPE program, be paired with a Mentor, and/or volunteer as a Mentor.
8
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1
Name
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First Name
Last Name
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2
E-mail
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3
Phone Number:
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Area Code
Phone Number
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4
Birth Date:
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-
Month
Day
Year
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5
Where did you hear about MentorSHPE?
*
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SHPE Website
Facebook
Instagram
Twitter
RLDC
Other
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6
Please select your membership type
*
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Junior
Student
Recent Grad
Graduate
Professional
Associate
Lifetime
Lifetime Associate
Not a member
I don't know my membership type
Junior
Student
Recent Grad
Graduate
Professional
Associate
Lifetime
Lifetime Associate
Not a member
I don't know my membership type
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7
Please select your current education or professional status:
*
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Middle School
High School
Undergrad - Freshman
Undergrad - Sophomore
Undergrad - Junior
Undergrad - Senior
Graduate - Master's or Professional Terminal Degree
Graduate - Doctoral Program
Early Professional (0-5 Years)
Mid Professional / Early Management (6-10 Years)
Senior Manager or Director
Senior Director or Executive Level
C-Suite
Associate or Adjunct Professor
Full-time Professor
Tenured Professor
Academic Administrator
Dean
Other
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8
Please select all that apply.
*
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I want to be a Mentee!
I want to be a Mentor.
I would like more information about MentorSHPE program altogether.
I do not wish to participate in MentorSHPE.
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