The NCCS - Mentor Application

Mentoring is when an experienced person (mentor) who is a knowledgeable and experienced guide, a trusted ally, and caring role model to another (mentee). Goals: Through this interaction the mentee will develop specific skills and knowledge that will enhance both the mentor and mentee’s personal growth.

Personal Information

Name*

First Middle Initial Last

Gender*

M
F

Preferred Phone*

Alternate Phone (if available)

Preferred Email*

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Year in College*

Ethnicity*

African American
Asian
White
Hispanic/Latino
Other

Ethnicity (if other, list below)

Diagnosis*

Year of Diagnosis*

Availability (check all that apply)*

Weekdays
Weekends
Mornings
Evenings

Mentor Application Form

Mentor Application Form

Online Mentor Application

Step 1 of 3 - Personal Info

Personal Information

About You

Mentor Agreement