Graduate and Professional Student - Mentor Form
Please fill out this form if you are interested in being a mentor to an undergraduate student!
Name (First, Last):
Your answer
Email:
Your answer
Cell Number:
Your answer
CU Net ID
Your answer
Age:
Your answer
Campus or Local Address:
Your answer
Ethnicity (check all that apply):
Sexual Orientation:
Gender Identity:
Academic Level:
What is your field of study?
Your answer
I was referred to the LGBT Peer Mentoring Program by:
Please provide TWO references (Reference 1):
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Reference Name:
Your answer
Contact Number:
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Contact Email:
Your answer
Relationship to You:
Your answer
Reference 2:
Your answer
Reference Name:
Your answer
Contact Number:
Your answer
Contact Email:
Your answer
Relationship to You:
Your answer
Why do you want to be a mentor?
Your answer
Describe relevant past experiences that have prepared you to be a mentor (e.g., volunteer experience, other mentoring programs, etc.).
Your answer
Describe someone who has been a mentor to you and what impact they had on your personal/professional development.
Your answer
How have you negotiated your own identity development process?
Your answer
This concludes the application. If you have any questions, please contact the LGBT Resource Center at LGBTRC@Cornell.edu.
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