Mentor’s Application Leave this field blank First Name Last Name Email Gender ManWomanotherPrefer not to disclose Racial Group Asian/Pacific Islander Black or African American Hispanic Native American White Other Prefer Not to Disclose Employer What is your title and division within your company? Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Work Phone Mobile Phone Date of Birth Have you previously participated in a formal mentoring program? Yes No Please describe your involvement with any other organizations (professional, civic, community, volunteer, etc.) What is the highest level of education that you have completed? High School Diploma/GEDSome CollegeAssociate's DegreeTechnical DegreeBachelor's DegreeGraduate DegreeOther Are you a retired company volunteer? Yes No Have you ever served in the military? Yes No Have any of your family members served in the military? Yes No Please provide a short introduction paragraph to be shared with your trainee Are you comfortable mentoring an active duty military spouse? Yes No Are you comfortable mentoring a disabled veteran? Yes No Unsure Are you comfortable working with a trainee who is experiencing or has experienced post-traumatic stress (PTS) and/or traumatic brain injury (TBI) symptoms? Yes No Unsure Are you comfortable mentoring a trainee who wants to start or grow a small business? Yes No Unsure Would you be open to having occasional one-off informational calls with trainee in our program in addition to your formal mentorship? Yes No List three fields in which you feel most comfortable mentoring. About which of the following preferences do you feel most strongly? My trainee has professional or corporate experience My trainee has little professional or corporate experience My trainee has similar leisure interests My trainee is at least ten years my junior My trainee is close to my age My trainee is the same gender as me. I have no preference. Please share any additional mentoring preferences you would like AHC to take into consideration. (optional) What are your favorite recreational activities? Attend cultural events Attend religious services Entertain in my home Go out to bars or restaurants Participate in sports and fitness Spend time outdoors Volunteer None / No Preference What are your LEAST favorite recreational activities? Attend cultural events Attend religious services Entertain in my home Go out to bars or restaurants Participate in sports and fitness Spend time outdoors Volunteer None / No Preference How did you learn about AHC's Mentoring Program? If you have a LinkedIn profile, include its URL here. https:// Photo Upload Choose fileUploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Does AHC have your permission to share your image, and quote you on our social media platforms, in our emails and newsletters, and in our presentations? Yes No Send
