Prospective mentor personal information
This information will be used to facilitate match with mentee(s).
Last name *
First name *
Preferred contact email *
Current institution / workplace (if retired, indicate last workplace and year of retirement) *
Location (city, country) of current institution / workplace *
Relevant career path *
Type of academic institution (if applicable)
Current position / title *
Time in current position *
Primary area(s) of scientific interest (check all that apply)
Do you wish personal descriptors provided below (ethnicity / race/ gender / sexual) to be shared / not shared with prospective mentee(s)? *
Can personal descriptors below (ethnicity / race/ gender / sexual) be made public on WormBase to facilitate mentees choosing candidate mentors? *
Do you consider yourself a minority in your current environment? *
How do you describe your race / ethnicity / ancestry? (check all that apply, and see next question to further specify)
Provide below additional details regarding race / ethnicity / ancestry, if desired, as these may impact mentor preferences of prospective mentees
How do you describe your sexual identity?
How do you describe your gender identity?
What are your preferred pronouns?
How would you describe your disability status?
Do you represent the first generation in your family to attend...
How would you describe the socio-economic situation of your upbringing?
Clear selection
Do you feel that you represent any other minority group in science that is relevant to your mentor / mentee relationship (religion, nationality, etc.)? If yes, please indicate below.
Is there anything else that is not captured above that the committee should know to help match you with a prospective mentee?
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