BLAZE Mentee Interest Form

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Please fill out all sections of this form. Please read and answer the following questions carefully. If you need guidance please do not hesitate to reach out to Dr. Debonair Oates-Primus at debona245@gmail.com. This form will be used to match you with your prospective mentor. It should be completed by August 31st. Pleas be advised that due to the fact that this is a pilot program with limited space, mentor preferences and program participation are not guaranteed.

Name *

Month and Day of Birth *

Race or Ethnicity

Gender

Language Proficiencies

Enrolled program *

Research or Career Interest *

What areas would you hope your mentor will make an impact? Please rank your choices in order of importance to you. *

Emotional Support

Career Goal Setting

Confidence Building

CV Development

Professional Networking

Utilizing support services

First Choice

Second Choice

Third Choice

Fourth Choice

Fifth Choice

Sixth Choice

How important is it that you and your mentor share the same racial identity? *

Extremely important

Very Important

Somewhat Important

Not Important At All

How important is it that you and your mentor share the same gender identity? *

Extremely Important

Very Important

Somewhat Important

Not Important At All

What year of your graduate program are you in? *

Have you been part of a mentorship program before? *

Yes

Please use the link below to access the mentor profiles. Once you are finished reviewing the profiles, please list your top three selections for a mentor. https://www.usciences.edu/about/diversity-equity-inclusion/blaze-mentors.html *

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