Mentor Information

NOTE:  As of August 22, we are now enrolling mentors to a Wait List.  We are grateful for your interest in the program and will be in touch if/when we have an opening.   Please continue to complete this form so that we can follow up as needed.   Thank you!  

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* 1. Mentor's Name and Address

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* 2. Mentor's Email Address

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* 3. Mentor's Contact Number

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* 4. Mentor's Birthdate

Birthdate

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* 8. Do you (Mentor) have any allergies or special needs?

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* 9. How did you hear about the program?  (select all that apply)

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* 10. Briefly explain why you would like to be a Ms President US Program Mentor and what you hope to gain from the experience:

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