: : Mentorship Application (for mentors)

Name:
Mailing Address:
City: State:
Zip:

E-mail:

Phone:

Desired level of involvement: (hint: level 3 is the correct answer!)
Level 1: (Example: attend mentor dinners)
Level 2: (Example: attend mentor dinners, attend events, answer e-mails)
Level 3: (Example: be a one-on-one mentor to an undergraduate student at UCLA plus all of the above if possible)

Please describe your current employment plus background in respective field:

Please describe any extra-curricular activities/hobbies you think may help us pair you with somebody:

What is your schedule/availability:

Please list your goals and any ideas you have for possible interactions: