ASCCC Faculty Empowerment and Leadership Academy

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ASCCC Faculty Empowerment and Leadership Academy - Mentor Application

This is the Mentor application for the ASCCC Faculty Empowerment and Leadership Academy.

Email *

First and Last Name *

College or Organizational Affiliation *

What is your discipline (if any)? *

What is your position on campus or at your organization? *

Email Address *

Phone number *

Given the FELA program mission, what makes you an ideal mentor for this program?

What is your experience with academic senate work?

Please list any leadership roles you have held (on campus, in your community, at state level, other organizations, or any informal roles)

What skills, areas, or special interests do you have that may contribute to your role as a mentor?

Do you have any prior mentor experience? If yes, please describe.

Anything you’d like to share to that would help the committee match you with a potential mentee?

How did you hear about the FELA program?

Photo and Vide Release

By participating in the FELA Academy, you agree to the following: "I agree to grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area."

Photographic, audio or video recordings may be used for the following purposes:

• conference presentations

• educational presentations or courses

• informational presentations or workshops

• on-line educational courses, presentations, or workshops

• educational videos and social media promotional content

Optional Demographic Section

The ASCCC aims to intentionally support the increase of development opportunities for diverse faculty, as called for in the ASCCC Strategic Plan 2018-2023 Goal 2 Objective 2.1. In order to design and lead professional development opportunities for diverse faculty, it is essential to begin gathering data to identify and meet the needs of the diverse faculty in our community college system. We ask that you please consider answering the following optional questions to help us identify the needs of our diverse faculty and also to effectively and thoughtfully match mentors with mentees. Please know that we value your voice and confidentiality, and this information will be secure and not shared or published without permission.

With which racial/ethnic group(s) do you identify? (check all that apply)

African American/Black

American Indian/Alaskan Native

Asian/Asian American

Caucasian/White

Latino/a/x/Chicano/a/x

Middle Eastern

Native American/First Nations

Pacific Islander

Decline to state

Other:

What is your sexual orientation? (check all that apply)

Asexual

Bisexual, pansexual, or fluid

Gay or lesbian

Heterosexual or straight

Queer

Decline to state

Other:

What is your current gender identity? (check all that apply)

Cisgender man (Cisgender is defined as a person whose gender identity aligns with their sex assigned at birth)

Cisgender woman (Cisgender is defined as a person whose gender identity aligns with their sex assigned at birth)

Gender non-conforming (Gender non-conforming is defined as a person whose behavior or appearance does not conform to traditional gender expectations)

Genderqueer/non-binary (Non-binary is defined as a person whose gender identity is not exclusively male or female)

Trans man (Transgender is defined as a person whose gender identity and/or expression is different from their sex assigned at birth)

Trans woman (Transgender is defined as a person whose gender identity and/or expression is different from their sex assigned at birth)

Decline to state

Other:

Agreement

By submitting this application form, you agree to the goals and purpose of the FELA mentoring program. ASCCC encourages an open exchange of information and ideas between members participating in the program. However, ASCCC cannot and does not review such communications and does not guarantee or endorse the accuracy of any information exchanged between mentor and mentee. You agree that you will participate in the program in a manner consistent with the ASCCC Mission and its constitution and bylaws. You further agree to completely release ASCCC, and its directors, from all claims, judgments, demands, liabilities, and actions that you may have arising out of, or in any way relating to, your participating in the mentorship program. I agree with the above terms, conditions, and goals of the mentor program.

A copy of your responses will be emailed to the address you provided.

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