New Mentor Form
Hi everyone! Please fill out the following form to be matched with a high school mentee for this school year. Before you fill out this form, make sure you have reviewed the information we covered at our 1st Fall GBM (09-08-22). The recordings for the meetings can be found here: and the slides were sent out via email/Slack. Please email us with any questions at Also, make sure the email address you provide below is your SCHOOL email!
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Email *
Provide an alternate form of contact (email, phone, etc.) *
If necessary, what is the maximum number of mentees you would be willing to take? *
Full Name *
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What school do you currently attend? (Ex: UIC, UIUC, etc) *
Major *
Year in School *
Pre-health track you are pursuing: *
How much time do you believe you would be able to dedicate to mentoring a high school student on a biweekly basis? (Please be honest it will help us match you with a mentee that has similar needs!) *
Please select the categories of universities that you applied to (check all that apply)
Please list all the universities you applied to that you would feel comfortable talking about with a mentee below. *
What is the name of the high school you attended? (Please include city if possible) *
Have you ever attended community college for a year or longer? (This does not include dual enrollment classes or summer courses you have taken) *
Please select the hobbies that you are interested in (This will help us identify someone that you will be able to connect with easier!) *
Please select the extracurricular activities you have been involved in (either currently or during high school)
What is your preferred form of contact? *
Please briefly explain why you would like to be a mentor. *
Some high schools may ask for our mentors to go through a background check before interacting with students. Is this something you would feel comfortable doing? *
Some high schools may ask you to provide a photocopy of an ID such as a driver's license. Is this something you would feel comfortable doing? *
Are there any preferences you have when being matched with a mentee? Is there something you would like us to consider? *
Do you identify with any of the following?
Checking any of the boxes below is completely optional. Only the President, Vice President, and Matching Chair of PHMN will have access to this information and it will only be used to fulfill specific requests by mentees.
Did you attend our first GBM? If not, have you reviewed the recording/ slides to look over what your duties as a mentor are? (Only those that have reviewed our first meeting slides are eligible to participate as a mentor) *
Would you be interested in participating in our Buddy System program that was discussed during the first GBM? *
Do you understand that if you can no longer mentor someone, or if issues arise with your mentee, it is your responsibility to inform the board promptly of this via email? *
By submitting this form, you are agreeing that you have understood the mentorship rules outlined at the first fall GBM and will abide by them. You also acknowledge that any inappropriate behavior will not be tolerated and will be grounds for immediate termination as a member of this club. Further action will be taken if necessary. *
If you have further questions about mentorship after reviewing our Fall 2022 GBM 1 Slides/Recording (09-08-22), please send all questions to
The slides can all be found on our Slack channel, and the invite will be displayed upon submission of this form.
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