Clark State Scholars: Mentor Application

First Name

Middle Name

Last Name

Email Address

Cell Phone

Is your phone able to receive SMS/Text messages?

Yes

No

Mailing Address

Country

Street

City

Region

Postal Code

How did you hear about the mentor program?

Availability: please select which applies

I can be flexible which day of the week/time I am scheduled to meet with Scholars

There are specific days/times I am available to meet with Scholars

If you are only available specific days/times, please share details:

Career Field/Industry:

Job Title:

Please select the highest level of education you've earned:

I attest the above information is correct and agree to the terms of this agreement.

Yes

No

I have read and agree to the terms of the Clark State Scholars Mentor Policies and Procedures located at the top of this page.

Yes

No