designing routes to education and mentorship

Application Form

Thank you for your interest in the dream Mentoring Program. Your help in filling out the following questionnaire is greatly appreciated. The information gathered will assist us in assuring we optimally utilize your skills and interests. Please ensure that you have read through the description of the dream mentoring program before continuing.

First Name:
Last Name:
Address:
Address 2:
City:
State/Province:
Country:
Phone:		(am) (pm)
Zip/Postal Code:
Email:
Confirm Email:
Please check:		Community Member Student Mentor

Why do you want to become a mentor in the dream Program?

My experience and expertise will contribute to the program by:

Specific activities I can and am willing to do to assist dream students are:

Check yes or no and provide an example:

1. I like the feeling of giving advice and guidance.	Yes No
2. Helping others learn is personally rewarding.	Yes No
3. I enjoy collaborative work.	Yes No
4. I find working with other people energizing.	Yes No
5. I want to further my own growth.	Yes No
6. I value education and want to help others value it also.	Yes No
7. I believe everyone has unlimited potential.	Yes No
8. I want to help others become socially aware and just.	Yes No

Indicate how comfortable you are in using each skill by writing one of the letters as follows:
V (very comfortable)
M (moderately comfortable)
U (uncomfortable)

Provide point form examples if possible.
Check column four for each skill you need developing.

Column: 1	2	3	4
Skill	V M U	Example	Needs Work
Communicating
Building relationships
Brokering relationships
Coaching
Encouraging
Facilitating
Goal Setting
Guiding
Managing Conflict
Problem Solving
Providing/receiving feedback
Reflecting
Multiple Intelligence	V M U	Example	Needs Work
Linguistic/Word Smart
Logical/Number Smart
Kinesthetic/Body Smart
Musical/Sound Smart
Spatial/Image Smart
Interpersonal/People Smart
Interpersonal/Self Smart
Naturalistic/Environment Smart

Thank you for your interest in dream mentoring!