The Coalition of Occupational Therapy Advocates for Diversity
Minority Mentorship Program Mentor Application

Thank you for your interest in MMP! Please note that we are currently accepting mentor applications for our Spring 2021 cohort. New mentor applicants will be matched with a mentee in January of 2021.
Email address *
Name *
Address (include city and state) *
Phone Number *
Preferred method of contact *
Required
How did you hear about this program? *
OT School attended, and graduation year *
Highest educational degree obtained
Clear selection
Were you a first-generation college student *
Were you a non-traditional student? *
Are you an AOTA Member *
Are you committed to regular communication with your mentee at least 1x/month? *
Do you speak any languages other than English? *
Your ethnic/cultural identity? *
Do you identify as an LGBTQIA+? *
Required
Years of OT/OTA experience: *
Current area(s) of practice: *
Primary interests in OT and others *
(Example: 1) Pediatrics 2) Academia 3) Leadership
Some people prefer mentors with similar lived experiences. Please list any factors that you feel would help you support a mentee. *
Please write a minimum of 1-2 sentences.
Briefly describe your interest in this program and what you hope to give and receive from participating? *
Anything specific you are seeking in a mentee? *
Submit
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