Academics

mentor application form

Name:
Date of Birth:
Address:
Phone:
	Home phone or cell phone number.
Email Address:
Degree Program:
Total Completed Credits:
G.P.A.:
High School:
	Please enter the high school from which you graduated. If no high school, please specify the path you took to a GED and the name of your local school district.
Family Income:
Number of People in Household:
Why did you decide to enroll in college?:
What do you hope to do with your degree?:
Describe your best personal qualities.:
How would you define the role of a mentor?:
Leadership and Mentoring Experience:
	Please describe your experiences with leadership and/or mentoring.
References:
	Please list here two references we may contact. Include the following: first and last names, how long you've known the reference, the nature of your relationship (employer, pastor, supervisor, colleague, etc.), a phone number, and if possible, an email address.
	Background check
	By checking this box you assert that you are willing to submit to a background check if selected as a Rural Scholars Mentor.
	First Generation College
	By checking this box you assert that you will be the first generation in your family (including parents, step-parents, and legal guardians) to complete a four-year college degree.