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* 1. Full Name:

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* 2. Phone Number:

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* 3. Email address:

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* 4. Age

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* 5. Community:

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* 6. Are you currently working in a leadership role in your community?

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* 7. If you answered yes to number 6, please select all that apply.

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* 8. Have you ever been a candidate in an election?

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* 9. If you answered yes to question 8, please select the applicable answer from the selections below.

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* 10. Have you participated in any of the Government FOCUS projects in the past? Check all that apply.

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* 11. Are you interested in participating in our Mentorship Program?

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* 12. Please select the kind(s) of mentorship programs you'd be interested in. Select one or more.

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* 13. At the conclusion of the Leadership School for Women, various topics were identified for further study/engagement. Please select three topics you'd like to see a group session cover.

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* 14. Please Identify three(3) topics of interest you'd like to learn about in One-on-One Mentor work. (Please skip this question if you are not interested in One-on-One sessions.)

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* 15. What supports would enable you to participate in one or more of these mentorship sessions (virtual or in-person). If you are interested in participating in both, please select all that apply.

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* 16. Do you identify with any of the following groups? Please select all that apply.

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* 17. If you identify as Indigenous/First Nation, would you like to learn more about the Kekina'muemk mentorship program design for Indigenous Women and Girls, and potentially participate?

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* 18. In your opinion, what is the most important outcome of mentorship?

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* 19. Why do you think Mentorship is important for women or girls in your community?

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* 20. Do you have any recommendations for any specific female leaders/mentors you'd like to see participate in a group session?

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* 21. Any additional comments or considerations?

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* 22. How did you learn about the Mentorship Program?

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