Mentee Application Survey

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1. What is your first and last name?

What is your first and last name?

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2. What is your home address?

What is your home address? Street
City
State
Zip Code

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3. Contact information:

Contact information: Home phone number
email address
parental email address

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4. What school do you attend?

What school do you attend?

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5. What grade (6th, 7th or 8th) will you be in for the 2011-2012 school year?

What grade (6th, 7th or 8th) will you be in for the 2011-2012 school year?

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6. How much do you know about jobs in the following?

	I know a lot about jobs in this field	I know a little bit about jobs in this field	I know nothing about jobs in this field
Science	*How much do you know about jobs in the following? Science I know a lot about jobs in this field	Science I know a little bit about jobs in this field	Science I know nothing about jobs in this field
Technology	Technology I know a lot about jobs in this field	Technology I know a little bit about jobs in this field	Technology I know nothing about jobs in this field
Engineering	Engineering I know a lot about jobs in this field	Engineering I know a little bit about jobs in this field	Engineering I know nothing about jobs in this field
Mathematics	Mathematics I know a lot about jobs in this field	Mathematics I know a little bit about jobs in this field	Mathematics I know nothing about jobs in this field

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7. Rate your interest in learning more about the following fields.

	Would love to learn more	I'm kind of interested in this	I've heard about it, would like to know more	I'm not interested at all
Science	*Rate your interest in learning more about the following fields. Science Would love to learn more	Science I'm kind of interested in this	Science I've heard about it, would like to know more	Science I'm not interested at all
Technology	Technology Would love to learn more	Technology I'm kind of interested in this	Technology I've heard about it, would like to know more	Technology I'm not interested at all
Engineering	Engineering Would love to learn more	Engineering I'm kind of interested in this	Engineering I've heard about it, would like to know more	Engineering I'm not interested at all
Mathematics	Mathematics Would love to learn more	Mathematics I'm kind of interested in this	Mathematics I've heard about it, would like to know more	Mathematics I'm not interested at all

8. Please list any clubs or organizations to which you belong

Please list any clubs or organizations to which you belong

9. What do you hope to learn from a Mentor?

What do you hope to learn from a Mentor?

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10. The STEM Mentor program requires weekly use of email. Are you willing to commit to checking your email at least once a week?

The STEM Mentor program requires weekly use of email. Are you willing to commit to checking your email at least once a week? Yes

Mentee Application
Exit this survey

1. Default Section

*
1. What is your first and last name?

*
2. What is your home address?

*
3. Contact information:

*
4. What school do you attend?

*
5. What grade (6th, 7th or 8th) will you be in for the 2011-2012 school year?

*
6. How much do you know about jobs in the following?

*
7. Rate your interest in learning more about the following fields.

8. Please list any clubs or organizations to which you belong

9. What do you hope to learn from a Mentor?

*
10. The STEM Mentor program requires weekly use of email. Are you willing to commit to checking your email at least once a week?

Mentee ApplicationExit this survey

1. Default Section

*1. What is your first and last name?

*2. What is your home address?

*3. Contact information:

*4. What school do you attend?

*5. What grade (6th, 7th or 8th) will you be in for the 2011-2012 school year?

*6. How much do you know about jobs in the following?

*7. Rate your interest in learning more about the following fields.

8. Please list any clubs or organizations to which you belong

9. What do you hope to learn from a Mentor?

*10. The STEM Mentor program requires weekly use of email. Are you willing to commit to checking your email at least once a week?

Mentee Application
Exit this survey

*
1. What is your first and last name?

*
2. What is your home address?

*
3. Contact information:

*
4. What school do you attend?

*
5. What grade (6th, 7th or 8th) will you be in for the 2011-2012 school year?

*
6. How much do you know about jobs in the following?

*
7. Rate your interest in learning more about the following fields.

*
10. The STEM Mentor program requires weekly use of email. Are you willing to commit to checking your email at least once a week?