Rev. 8/18/16
Name: _______________________ ____ ______________________ Gender: Male Female
First MI Last
Home Address:_______________________________________________________________________________
Number Street Apt # City Zip Code
Phone Number: (_______)_________________________
E-Mail Address: _____________________________________________
Current Occupation: _________________________________________
Company Name: _____________________________________________________________________________
Company Address: ___________________________________________________________________________
Number Street City Zip Code
Business Phone: (_____)_________________________
Title and Responsibilities: _____________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Briefly describe your professional, Work, and Career Background: __________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Briefly describe your hobbies, interests and/or talents: _____________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Education:
Associates:_____________ Major(s): ___________________________ From:__________________________
Bachelor’s: ____________ Major(s):____________________________From:__________________________
Master’s: _____________ Major(s):____________________________From:__________________________
Doctorate:_____________ Area: _______________________________From:__________________________
Professional Degree: __________Area:________________________ From:__________________________
MT. SAN JACINTO COLLEGE
PUENTE MENTOR PROFILE FORM
All information will be held in strict confidence. Please PRINT legibly in BLUE or BLACK INK and complete all information.
FILL
 
Rev. 8/18/16
Who was an important role model or mentor for you and why?
If you have worked with community college students, please describe your experience(s):
Are you affiliated with any community, civic, or professional organizations? If so, which ones?
Do you speak Spanish? Yes No If yes, Fluently Limited
Mentor Agreement
If I am matched with a Puente student, I agree to (please read and initial):
1. Commit to mentor a student for 1 academic year (2 semesters). ________
2. Meet with my mentee(s) for at least 18 hours over the academic year (9 hours/semester). _______
3. Call my student(s) at least once a month to help maintain contact. _______
4. Help my student with mentor related classroom assignments. _______
5. Acquaint my mentee(s) with my educational and career background and professional expertise. ______
6. Serve as a positive role model and encourage the achievement of higher education. _______
7. Support my fellow mentors by sharing my mentor experience. _______
8. Participate in mentor related activities. _______
Signature: _____________________________________ Date:_________________________
Please Return Completed Form To:
or
Rosalva Amezcua, Counselor
ramezcua@msjc.edu
Counseling Office
San Jacinto Campus
1499 N. State St.
San Jacinto, CA 92583
Rebecca Coleman, English Instructor
rcoleman@msjc.edu
Library Room 320
San Jacinto Campus
1499 N. State St.
San Jacinto, CA 92583
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