2018-19 STEM Mentor Program Mentor Enrollment Form

The STEM Mentor Program is a partnership between MassBay Community College and regional STEM employers, originally launched in 2014 in conjunction with Sanofi Genzyme. The STEM Mentor Program pairs professionals (mentors) working in STEM fields with MassBay STEM students (mentees) to facilitate one-on-one mentoring relationships. This program gives mentors the opportunity to play an active role in the educational and professional development of MassBay students, to help shape future leaders in STEM careers, and to meet potential future interns and employees.

Your answers to the questions below will help us learn about your background and pair you with a suitable mentee(s). This enrollment form should take approximately 10 minutes to complete. Please note that you must complete the enrollment form in its entirety before submitting. There is no option to save and edit at a later date.

Thank you for your participation!

CONTACT INFORMATION

1. First name: *This question is required.

2. Last name: *This question is required.

Employer name: *This question is required.

4. Employer location:

5. Job Title: *This question is required.

6. Work email: *This question is required. This question requires a valid email address.

7. Personal email This question requires a valid email address.

8. In which city/town do you reside?

9. Preferred phone (with dashes, e.g.: 617-555-1234): *This question is required.

10. Do you have a cell phone number at which we can contact you via text?

Cell phone number (with dashes, e.g.: 617-555-1234):

WORK INFORMATION

11. How long have you been employed in your field?

12. What do you consider your primary area(s) of expertise?

EDUCATIONAL BACKGROUND

13. What was/is your primary field(s) of study?

14. What is your highest level of education/degree?

15. Are you the first in your family to graduate with a college degree?

16. Have you ever attended community college?

Which community college did you attend?

PROGRAM PARTICIPATION

17. In which activities would you like to participate with your mentee? (Please check all that apply.)

18. What is your preferred meeting location(s)?

Your workplace
MassBay Wellesley Campus
Other, please specify Please enter an 'other' value for this selection.

19. How many hours per month are you willing to commit to your mentee?

20. Are you willing to mentor more than one mentee? *This question is required.

How many mentees are you willing to mentor?

21. What is your general availability for meeting your mentee? (select all that apply)

Business hours-weekdays
Evenings
Weekends

22. Is there anything you would like to add that may help us in the mentor/mentee matching?

23. What do you hope to get out of the mentoring experience?

24. If you have any colleagues or associates working in a STEM-related field who are interested in learning more about mentorship opportunities with the MassBay STEM Mentor Program, please include their name and contact information (email and/or telephone). Thank you!

DEMOGRAPHIC INFORMATION

25. Gender identity:

26. Please specify your ethnicity:

Please enter an 'other' value for this selection.

27. Please specify your age:

28. Are you a veteran or active member of the military?