Tusculum University-Greeneville-SSS-Mentor Application

SSS Pioneering Connections Application

Name*

First NameLast Name

Date

mm-dd-yyyy

Date of Birth

mm-dd-yyyy

Housing

I live on campus.I commute from home.

If you live on campus, what dorm do you live in?

Phone

(999)999-9999

TU Email*

example@students.tusculum.edu

Major

Minor (if applicable)

Current GPA

Polo Shirt Size

Are you planning on working in another position on campus?

How many hours per week will you be working?

0-9hrs. / wk10-19hrs. /wk20-29hrs. /wk30-40hrs. /wk

List your Clubs/Organizations and your leadership role in each (if applicable)

	Club/Organization	Leadership role (if applicable)
1.
2.
3.
4.
5.
6.

Character Information

Name your personal interests: (favorite sport(s), hobbies, recreation, or other activities)

What strengths will you bring to the SSS Pioneering Connections Mentor Program?

Why do you feel mentorship is important for both mentor and mentee?

What do you hope to gain from this experience?

Please describe a mentoring (as a mentor or mentee) experience you have had. Be specific and explain how you believe this will affect you as a mentor, as well as what your objectives will be as a mentor. If not, what would you want in a mentoring experience?

What are your opinions about diversity in the collegiate environment?

Is there any other information about yourself that would help us in matching you?

Mentoring Contract

I agree, if accepted as a mentor, to follow the mentoring rules and regulations set forth by Pioneering Connections governing body and I will also adhere to all Tusculum University policies, which if violated, could affect my status as a mentor in the program. In addition, I will attend all of the mentoring training sessions.

Print Name

First NameLast Name

Signature

Date

mm-dd-yyyy

*Once submitted, the applicant should email the recommendation link found on the SSS webpage to their reference of choice.