Heartland Community College
     
 
 
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All fields are required unless marked as optional.
 
Applicant Name:
 
Mailing Address:
 
Email:
 
Phone Number:
 
Current Employer:
 
Current Position Title:
 
Dates Employment:
 
Description of Duties:
 
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List any certificates/degrees you have earned AND the issuing institution.
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Attach Resume:
 
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Gender:
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Gender Open Response:
 
*Please fill out this field only if you selected open response on the last question.Ethnicity:
 
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Ethnicity Open Response:
 
*Please fill out this field only if you selected open response on the last question.Support Group:
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Support Group Open Response:*Please fill out this field only if you selected open response on the last question.
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Of the groups identified above, do you have a preference when pairing with a mentee?
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What are your mentee preferences? List your preferences here.*Please only fill this field if you checked yes for the previous question.
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Why do you want to be a mentor?
 
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Have you been in a mentoring relationship, either formally or informally? If yes, tell us about the circumstances of your experience.
 
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What are your hobbies and interests?
 
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Mentees and mentors are expected to meet at least monthly. When are you most likely available?
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I understand that information provided within this application will be used to determine a good match for a mentoring relationship. My information will be provided to my matched mentee prior to our first meeting.
Outside of sharing this information with my mentee, information provided within is confidential and will not be used or disclosed by the College. 
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