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. 

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* 1. Please provide your full name:

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* 2. Please provide your degree(s):

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* 3. Please provide your pronoun(s):

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* 4. Please provide your work addresses:

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* 5. At what email address would you like to be contacted?

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* 6. At what phone number would you like to be contacted?

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* 7. Preferred contact method:

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* 8. Are you currently an MPA member??

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* 9. Are you currently licensed in Massachusetts?

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* 10. What is your experience level?

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* 11. Why do you want to be a mentor?

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* 12. What are your areas of experience: Setting?  Check all that apply.

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* 13. What are your areas of experience: Activity?  Check all that apply.

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* 14. Which areas do you feel qualified to mentor? Check your top three only.

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* 15. Please provide any additional information about topics that you are able to provide mentoring:

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* 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.

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* 17. Please indicate what type of meetings you prefer:

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* 18. What length of commitment are you interested in?

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* 19. Please add any other information you would like to share:

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* 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.

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* 21. Today's date:

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