PRIDE Mentoring Mentee Application

Please answer these questions carefully. They will be used to match you with a mentor who has similar interests. Your responses will be kept confidential and files will be kept secure.

Required fields are marked with an asterisk (*).

First Name *

Preferred/Lived Name

Last Name *

Race / Ethnicity *

Gender

Please share your gender (optional)

Please share your preferred pronouns (optional)

Birthdate *

Home Address

Country

City

Region

Postal Code

Home Phone Number

Mobile Phone Number *

Email Address *

Are you a U.S. citizen or legal permanent resident?

Yes

No

Please give your country of residence

Are you an international student?

Yes

No

What is your preferred method of communication? *

Phone

Email

Please describe

Please select your current academic year *

Major (Please write "undeclared" if no major has been chosen yet) *

Short Answer Questions

Please describe how a mentoring program would benefit you *

Write a brief statement on why you have chosen to participate in the Rider PRIDER Mentoring Program *

Are there any specific areas that you would like to focus on within the mentoring program? *

Yes

No

Please explain *

What qualities do you think a good mentor should have? *

What do you hope to gain from the mentoring program? *

Reference Information

Please provide one (1) to two (2) references:

Reference 1 (Optional)

Reference Name

Reference Email

Reference Phone Number

Reference Relationship

Reference 2 (Optional)

Reference Name

Reference Email

Reference Phone Number

Reference Relationship

Mentor Pairing Information

Do you speak a foreign language? If so, please explain in detail.

Please list any hobbies or interests you have? *

What kind of activities would you like to enjoy with a mentor? *

My favorite subject in high school was... *

My least favorite subject in high school was... *

What individual has served as a role model for you thus far? Why? *

Additional Information

What is the best time of day for you to meet with your mentor? *

Morning (8:30 am - 11:00 am)

Afternoon (11:00 am - 3:00 pm)

Evenings (3:00 pm - 7:00 pm)

Please list specific times if you are able to

What is your T-shirt size?

Disclaimer *
I understand that by applying to this position/program, I agree that the head of CDI may conduct a “student conduct background check” on my records while a student here at Rider University.

Further, I agree that, depending on the nature and severity of my student conduct history, I may be excluded from obtaining this position or being a part of this program.

I also agree that if I do obtain this position, or if I am accepted into this program, and at a later date, I receive an allegation of misconduct, I must seek to discuss the situation with the head of CDI immediately.

The nature and severity of that incident may be grounds for my dismissal from this position/program.

By checking this box, I certify to the best of my ability that the information provided here on the application is true and accurate and that I understand the above language on my conduct while at Rider.