Mentorship Program Application Form

Mentorship Program Application Form

RECITALS

WHEREAS, the Organization identified below operates a structured mentorship program to support professional development and skills transfer; and

WHEREAS, the Applicant seeks to participate in the mentorship program in the capacity indicated on this form and agrees to comply with the Program Terms and Conditions set forth herein;

WHEREAS, participation is subject to acceptance by the Organization and adherence to confidentiality, scheduling, and conduct requirements established by the Organization.

PROGRAM & APPLICANT IDENTIFICATION

PROGRAM SELECTION & AVAILABILITY

I apply to participate as: Mentor Mentee

One-on-one Group mentoring Virtual In-person

SCOPE OF WORK / MENTORSHIP OBJECTIVES

Describe the primary goals, deliverables, topics, or competencies you intend to address during the mentorship. Be specific about measurable outcomes where possible.

BACKGROUND & RELEVANT EXPERIENCE

REFERENCES

PAYMENT TERMS (IF APPLICABLE)

If the mentorship involves fees, state the fee, payment schedule, and late fee policy below. If no fee applies, enter "N/A".

TERM AND TERMINATION

The mentorship term and termination provisions regulate the effective dates and notice requirements for early withdrawal or termination by either party.

CONFIDENTIALITY & CONDUCT

Applicant acknowledges that mentoring discussions may include confidential and proprietary information. Applicant agrees to maintain the confidentiality of any confidential information disclosed during the mentorship and not to use such information for any purpose other than participation in the Program, except with prior written consent of the disclosing party or as required by law.

Applicant further agrees to conduct themselves professionally and to abide by any code of conduct or conflict-of-interest rules provided by the Organization. The Organization may suspend or terminate participation for breaches of confidentiality, failure to attend scheduled meetings without notice, or conduct detrimental to participants or the Program.

By checking this box, I acknowledge and agree to comply with the confidentiality and conduct obligations described above.

DATA USE & MEDIA RELEASE

The Organization may use aggregated, de-identified program data for internal reporting and program evaluation. Any use of Applicant's name, likeness, or testimonial in promotional materials will require separate written consent unless Applicant expressly grants permission below.

Yes, I consent to limited use of my name or likeness for Program promotional materials. No, I do not consent.

GOVERNING LAW & ENTIRE AGREEMENT

This Application, together with any acceptance and any Program Terms provided by the Organization, constitutes the entire agreement between the parties concerning Applicant's participation in the mentorship Program and supersedes prior discussions and representations. Any dispute arising from or relating to this Application or Applicant's participation shall be governed by the substantive laws of the state or jurisdiction of the Organization's principal place of business, without regard to its conflict-of-law principles.

CERTIFICATION

By signing below, Applicant certifies that all information provided in this Application is true and accurate to the best of Applicant's knowledge, that Applicant agrees to the terms and conditions set forth in this document, and that Applicant understands that submission of this Application does not guarantee placement in the Program. Applicant further authorizes the Organization to contact references provided for the purpose of evaluating this Application.

By checking this box and submitting this form, I certify that the electronic representation of my signature below is the legal equivalent of my handwritten signature.

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