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Mentor 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 mentee; however, following a match, your mentee 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 is your experience level?(Required.)
11.Why do you want to be a mentor?(Required.)
12.What are your areas of experience: Setting?  Check all that apply.(Required.)
13.What are your areas of experience: Activity?  Check all that apply.(Required.)
14.Which areas do you feel qualified to mentor? Check your top three only.(Required.)
15.Please provide any additional information about topics that you are able to provide mentoring:(Required.)
16.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 mentee. NOTE: This information is not required and will only be used for matching purposes.
17.Please indicate what type of meetings you prefer:(Required.)
18.What length of commitment are you interested in?(Required.)
19.Please add any other information you would like to share:
20.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.)
21.Today's date:(Required.)