First Name *

Last Name *

What is the best email address for you? *

What is your preferred contact phone number? *

Your age group *
- Select Option 18 to 24 25 to 39 40 to 60 60+ Prefer not to answer

Ethnicity: *
- Select Option American Indian or Alaska Native (e.g., Navajo Nation, Blackfeet Tribe, Inupiat Traditional Gov't., etc.) Asian or Asian American (e.g., Chinese, Japanese, Filipino, Korean, South Asian, Vietnamese, etc.) Black or African American (e.g., Jamaican, Nigerian, Haitian, Ethiopian, etc.) Hispanic or Latino/a (e.g., Puerto Rican, Mexican, Cuban, Salvadoran, Colombian, etc.) Middle Eastern or North African (e.g., Lebanese, Iranian, Egyptian, Moroccan, Israeli, Palestinian, etc.) Native Hawai`ian or Pacific Islander (e.g., Samoan, Guamanian, Chamorro, Tongan, etc.) White or European (e.g., German, Irish, English, Italian, Polish, French, etc.) Not listed Please specify a value for Ethnicity:

Do you speak any languages other than English? *
- Select Option Yes No

What is the level of education have you completed? *
- Select Option High School diploma Some college Bachelor's Degree Master's Degree PhD Not listed Please specify a value for What is the level of education have you completed?

Are you GVSU alumni? *
- Select Option Yes No

What was your major/concentration of study? *

Profession or former profession: *

Where is your hometown? *

What style of mentorship would you be interested in doing? *
One to one mentoring
Group mentoring
Online mentoring

Can you commit to dedicating one hour a month for 12 months to the mentorship program? *

Mentorship meetings can take place in person, on the phone or video chat. Do you have a communication preference? *
I prefer to meet in person
I'm more of a phone person
I enjoy video chatting
I open to all of the above

Below are the Mentorship Engagement programs/outings (select the ones you are available to attend) *
NIARA Fall Welcome: Thursday, August 29 4PM-5:30PM in Grand River Room- Kirkhof Room 2250
(Outing) Rockstar Women's Brunch: Sunday, September 22nd
NIARA Mentor Mixer: Thursday, October 10th 4PM-5:30PM in Kirkhof Room 2263
Outing-Young Professionals of Color Conference: Wednesday, October 16th
NIARA End of the Year Celebration: Thursday, December 5th 4PM-5:30PM in Kirkhof Room 2263

What are your interests and hobbies? (these answers help us pair you with a student) *

Why are you interested in becoming a mentor with the NIARA Program? *

Are there any specific skills or areas you hope to develop further and receive guidance? *