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Mentor Application

Telementoring Needs You

Become An On-Line Mentor

To be eligible to serve as an on-line mentor to high school women i n science and engineering classes, please take the time to answer the following questions. Your responses will help us c onsider the best possible match between you and the students.

Name
Day PhoneEvening Phone
E-Mail Address
Age18-25
25-29
30-39
40-49
50+
Job Title
Institution/ Company
Mailing Address (no P.O. Boxes please) :Work/School Address:
StreetStreet
City City
StateState
ZipZip

Occupational Field
Engineering
Physics & Astronomy
Mathematics
Computational Science
Computer Programm ing / Software Development
Biomedical Sciences
Chemistry
Earth Science / Geology / Meteorology
Social Sciences & Psychology
Humanities
Business
Other...
Number of Years in Your Profession 1 year or less
1-5 years
5-10 years
10-15 years
15 years +
Please indicate your racial/ethnic group
Asian/Pacific Islander
Hispanic / Latina (any race)
Black / African-American
Native American / Aleutian Islander
White (non-Latino)
Other...

Please check the highest level of education completed
Some college
College graduate
Masters
PhD
Post-doctoral Work
Other...
What written languages, other than English, are you well versed in?

Professional Memberships/Associations

Hobbies/Interests

Your Work and You

  1. What is your field of work or study? What do you find most exciting or personally compelling about it? What do you like least about it?

  2. Why did you choose the particular scientific or technical field you are in? Did anyone influence that decision?

  3. As a woman, what are the challenges that you have had to face in your field?

  4. Do you use visualization tools or software for data analysis or other work that you do? Please describe.

  5. What kind of advice would you give a young woman who is reluctant to pursue science because of mathematics anxiety ? What role has mathematics played in your career development?

Thoughts & Experiences About Mentoring

  1. Have you ever been a mentor?
    yes no
  2. If yes, please note what kind of mentoring you have done:
    informal mentoring of a younger person
    mentoring in a formal program
    workplace mentoring of colleagues
    Other...
  3. Have you ever been mentored?
    yes no
  4. If you had a mentor, has that mentoring experience helped you in your own career?

  5. Why do you want to be a mentor to high school girls?

  6. Would you be willing to participate in on-line mentor training?
    yes no
  7. How often would you be willing to communicate online with students?
    once a week
    twice a week
    once every two weeks
    once a month
  8. Is there anything that you would like to add about yourself or your interests that would help us match you to a student?

  9. What topics do you feel most prepared to discuss with a mentee? (Please check those options that appeal most to you.):
    College Preparation
    Financial planni ng for college
    Applications
    Course selection
    Study skills
    Info about college life

    Resources & Networks
    Tutoring
    Accelerated and/or summer programs
    Internships
    Supporting Organizations

    Career Awareness

    Career Opportunities
    A day in the life of a scientist
    Interviewing
    Resumes / References

    Diversity Issues
    Opportunities for Students of Color
    Affirmative Action
    Getting Along in Diverse Groups
    Prejudice and Racism

    Personal Development
    Balancing family and work
    Sexual harrassment
    Self image and self confidence
    Time management

    Telecommunications

  10. Including the current year, for how many years have you been using telecommunications? (Choose "zero" if you have never used it before.)
    zero yrs
    less than one yr
    1-2 yrs
    2-5 yrs
    5+ yrs
  1. How much experience do you h ave with telecommunications? Please check the statement that best describes your experiences with telecommunications.
    I am interested in learning telecommunications but haven't had a good reason to use it yet
    I am still learning the basics of telecommunicating and rely on other people and resources to support my development
    I am still learning the basics of telecommunicating and I am struggling on my own to do so
    I would describe myself at an intermediate level. I am no longer a beginner, but I have more to learn
    I have been doing telecommunications for a number of years and feel very comfortable and confident with the technolo gy
    Other Please describe:
  2. Which of the following uses of telecomm unications applies to you?
    online databases
    online services
    bulletin boards
    email systems
    telnet
    file transfer

  3. How did you find out about us?

©1995 Education D evelopment Center, Inc.

Last Revision: 12/1/99