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Mentee Profile Form for the College Success Program
We're glad to hear you are interested in working with one of our mentors. After you submit this form we will set up some time to connect over the phone and orient you to the mentoring program. . If you have any questions in the mean time, please reach out to Abigail Shaw (
afshaw@learningally.org
) 212-845-7007
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* Indicates required question
First name:
*
Your answer
Last name:
*
Your answer
Birth date:
*
Your answer
My gender identity is (check all that apply):
*
Woman
Man
Transgender Woman
Transgender Man
Genderqueer
Questioning or Unsure
An identity not listed
Other:
Required
I use the pronouns:
*
she/her/hers
he/his/him
they/them/their
Other:
Personal e-mail (the one you check on a regular basis):
*
Your answer
Best phone number for us to reach you at:
*
Your answer
I heard about the program through:
*
Your answer
I attend school/I am planning to attend school at:
*
Your answer
I live in [Please enter City/State]:
*
Your answer
If you have completed any credits towards your degree please list them below:
Your answer
My field of study/career of interest is:
*
Your answer
My visual impairment is due to:
*
Your answer
I have:
*
No residual vision
Some vision
A lot of usable residual vision
I have additional disabilities:
*
Yes
No
If you answered yes above, please describe your additional disabilities.
Your answer
Besides English, I speak the following languages:
Your answer
Indicate which methods you use for reading. Check all that apply.
*
Large print
Braille
Audio
Required
Please describe the types of assistive technology you use for recreational and academic purposes (i.e. portable CCTV, braille note taker, JAWS/VoiceOver, etc.):
*
Your answer
Do you use any of the following for independent mobility?
*
An ID cane
White cane
Service animal
Wheelchair
Walker
Prosthetic limb
I don't use any mobility aids.
Other:
Required
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