WAPA MENTORING PROGRAM

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Please complete the following form and send it as an email attachment or a printed page to the mentorship program chair. Allow two weeks for processing and feedback from your potential mentor. You should receive an acknowledgement of receipt of this form when you submit it to the chair.

Are you a new or current member of WAPA? _____New Member _____Current Member

Name (Last, First, MI):

Home Address:

City, State, and Zip Code:

Daytime Phone (w/area code): ( ) Evening Phone (w/area code): ( )

Email:

Employer, Affiliation or University:

Position/Title or Current Student Standing:

Please list two or three topical areas of interest:

Please list two or three geographical areas of interest:

Please describe your current status: (check all that apply)

___Currently employed full time ___Currently employed part time

___Working student ___Full-time Student

___Currently unemployed ___Currently employed but seeking change

___New to area ___Other (please specify):

Highest Degree Obtained (check one) ___Ph.D. ___Ed.D. ___Masters ___Bachelors

Other:

Select a Mentor

If you do not already have three candidates in mind, please consult a WAPA member directory and identify three potential mentors. List their names here, in order of preference:

1.

2.

3.

Briefly describe below what kinds of help you would like to receive from a mentor:

Briefly describe your career goals, concerns, and other issues you feel are relevant for a mentor:

Please feel free to submit additional notes or comments, or suggestions on how we can improve the application process:

Thank you for your interest in the WAPA mentoring program. Please Email or mail your completed form to mentorship chair Jo Anne Schneider at jschneid@gwu.edu. She should contact you shortly with the name and contact information of the person who has agreed to mentor you.

In case you are unable to save or submit this form, you may print and mail it to:

WAPA Mentorship Program

P.O. Box 23262, L'Enfant Plaza Station

Washington, D.C. 20026