Student Mentor Program Application

STUDENT MENTOR PROGRAM APPLICATION

This application collects information necessary to evaluate candidacy for participation as a Student Mentor in the Student Mentor Program. Completion of this application authorizes program staff to verify academic status and contact references. Applicants accepted into the program must comply with program policies, attend required training, and adhere to confidentiality and conduct standards described below.

Applicant Information

Date of Birth:    Student ID:    Grade / Program:

Expected Graduation:    Cumulative GPA:    Major / Program Focus:

Academic & Mentoring Experience

Are you currently enrolled and in good academic standing?   Yes

Availability & Commitments

Preferred Days / Times (check all that apply):
Mon   Tue   Wed   Thu   Fri   Sat   Sun

Program Term / Semester Start Date:    I commit to attend required mentor training and to maintain the minimum program participation for the full term:

Emergency Contact & Health Information

Relationship:    Phone:    Alternate Phone:

References

Personal Statement

Program Policies, Consent & Certification

Eligibility: Applicants must be enrolled students in good academic standing and meet any program-specific grade or course prerequisites. Acceptance is contingent on review of academic record and references.

Confidentiality: As a mentor, I will maintain the confidentiality of mentee records and discussions except where disclosure is required by law or to protect safety. I understand that unauthorized disclosure of protected information may result in removal from the program.

Training & Attendance: Mentors must complete required orientation and training prior to engaging with mentees and must notify program staff promptly of unavoidable absences. Repeated unexcused absences may result in suspension or dismissal.

Background Check Consent: I authorize the Student Mentor Program to obtain and review background and eligibility information, including verification of academic records and criminal history checks where permitted. I understand that a disqualifying background result may render me ineligible for participation.

Data Use: Information collected on this application will be used solely for evaluation, placement, and program administration. Program staff may share necessary information with program partners and school officials on a need-to-know basis.

Media Release: I grant permission for program staff to use photographs or video that may include my image for program promotional materials, unless I opt out below.
I CONSENT    I DO NOT CONSENT

Certification: By signing below I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that intentionally providing false information may result in denial or dismissal from the program.

I authorize verification of the information provided and give permission for the Student Mentor Program to contact listed references and appropriate school officials. I acknowledge that acceptance into the program is at the sole discretion of program administrators.

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