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Mentee Application: MPA Mentorship Program

Thank you for your interest in MPA's Mentorship Program. The information that you provide in this application will be used to facilitate the best possible mentor/mentee match. Generally, the information you provide will not be shared with your mentor; however, following a match, your mentor will be given your name and contact information. 
1.Please provide your full name:(Required.)
2.Please provide your degree(s):(Required.)
3.Please provide your pronoun(s):(Required.)
4.Please provide your work addresses:(Required.)
5.At what email address would you like to be contacted?(Required.)
6.At what phone number would you like to be contacted?(Required.)
7.Preferred contact method:(Required.)
8.Are you currently an MPA member??(Required.)
9.Are you currently licensed in Massachusetts?(Required.)
10.What experience level of a mentor do you seek?(Required.)
11.Why do you seek a mentor?(Required.)
12.What are your areas of experience: Setting?  Check all that apply.(Required.)
13.What topics do you seek mentoring in?  Check your top three only.(Required.)
14.Please provide any additional information about topics that you would like to be the focus of mentoring (if applicable). For example, if you noted that you would like to receive mentoring about teaching or research, you can specify the specific teaching areas or research areas in which you are interested.(Required.)
15.If you would like to be matched based on gender identity, ethnicity, race, sexual orientation, spiritual/religious background, or other aspects of culture/identity, then please provide information below about: (1) your own culture/identity and/or (b) what you are looking for in the culture/identity of a mentor. NOTE: This information is not required and will only be used for matching purposes.
16.Please indicate what type of meetings you prefer:(Required.)
17.What length of commitment are you interested in?(Required.)
18.Please add any other information you would like to share:(Required.)
19.By typing my name below, I attest that I have answered the questions in this application honestly and I consent to the use of this information for purposes of participating in the MPA Mentorship Program.  I understand that, once matched, I will adhere to the program guidelines, including the program evaluation.(Required.)
20.Today's date:(Required.)