Fillable Mentor Profile Form (Mt. San Jacinto Community College District)

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Mentor Profile Form (Mt. San Jacinto Community College District)

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The Mentor Profile Form (Mt. San Jacinto Community College District) form is 2 pages long and contains:

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  • 4 check-boxes
  • 53 other fields

Country of origin: US
File type: PDF

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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.
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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Mentor Profile Form (Mt. San Jacinto Community College District)

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Completed 26 July 2020

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