Mentor Matching Questionnaire

PERSONAL DETAILS
Name:(*)
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Email:(*)
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Best Contact Phone Number:(*)
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PROFESSIONAL EXPERIENCE
Current Place of Employment:(*)
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Current Job Title:(*)
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Please briefly describe your work experience:(*)
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OTHER INTERESTS
Please list 3 or 4 key areas of personal interests outside of work (i.e. gardening, working with youth, painting, reading, etc.)(*)
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MENTORING
Have you previously been involved as a mentor in any other programs?(*)

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If yes, please briefly describe here:(*)
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Are you able to commit the necessary time (attend weekend CHIA workshop and provide support during the CHIA process) to a grantee applicant?(*)

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What do you believe you can offer to a grantee applicant who is going through the CHIA process?(*)
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Is there anything else you would like to tell us or think would help the matching process? (e.g., professional interest, previous experience or knowledge of a particular community or neighborhood in the area etc.).
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(*)
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