UIW Honors Mentor Alumni Registration Form

Full Name*

First Name

Last Name

Street Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone Number*

Enter the best number to reach you.

Email*

Current Job Title*

Employer*

Additional Degrees and Credentials*

Graduate degrees, professional certifications, etc.

Mentors may elect to work with a single student, a small group of students who share a professional interest, or serve as a consultant to a larger group of students such as a theme-based Honors Living Learning Community or group of students working on an initiative they are passionate about. Perhaps a student could spend a work day with you. Which type of mentorship would you be willing to provide?

Mentoring Options*

Single student Small group Consult with a student group Have a student shadow you for a day. Check All That Apply.

Check All That Apply.

Why are you interested in being an alumni mentor?*

What do you expect to gain from the relationship?*

Please rate each of the following four modes of communication for your preferred way to communicate with your mentee. Rate your preference from 1 to 5, with 1 being your least preferred and 5 being your most preferred mode.

Telephone Preference*

1 2 3 4 5

Rate preference from 1 to 5, with 1 your least and 5 your most preferred.

In-Person Preference*

1 2 3 4 5

Rate preference from 1 to 5, with 1 your least and 5 your most preferred.

Email Preference*

1 2 3 4 5

Rate preference from 1 to 5, with 1 your least and 5 your most preferred.

Video Chat (Skype, Facetime, WhatsApp, etc.)*

1 2 3 4 5

Rate preference from 1 to 5, with 1 your least and 5 your most preferred.

If your preferred meeting modality is in-person, please specify your preferred location:

Schedule Availability*

Weekday Week night Weekend

Click all that apply

What types of professional personal development topic, or areas of expertise, are you most interested in sharing with a student?*

For those interested in working with groups of students, please describe any areas of interest, talents, skills or background that you might wish to share as a mentor.

Additional Comments

I acknowledge that if I am selected to participate in the UIW Honors Program Alumni Mentoring Network, I will abide by its guidelines as described on the UIW Honors Program Alumni Mentoring Network web page.

Signed Agreement

I agree to the above terms of participation.*

I agree to the above terms of participation.