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Mentorship Registration Form | Employment + Education Centre
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Services
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Mentorship Registration Form
Job Seekers
Employment Coaching
Job Board
Hospitality Program
Pathways To Production
Resource Centre
Career Mentorship
Online Client Registration Form
First Name
Last Name
Address
City
State/Province
Zip/Postal Code
Email Address
Phone
Age
Preferred Contact Mode
Email
Phone Cell
Text Message
Fluent Language
English
French
Other:
Preferred mentor language, if not English*
Career Interest(s)
What do you hope to gain from a mentoring relationship?
*Roots to Wings will attempt to accommodate requests for mentorship in languages other than English whenever possible. Please be aware that we cannot guarantee to meet this request.
Are you currently in school?
YES
Current School
Grade/Year
Current program or favourite subject(s)
NO
Former School
Years
Program or favourite study
Current Employment Status:
F/T
P/T
Position
Employer
Unemployed
Other interests in or outside of school/work
Check your preferred meeting times
Morning
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Emergency Please Contact
Name
Relationship
Home Phone
Alternate Phone
If there are any medical conditions (e.g., severe allergies) or specific emergency treatments (e.g., Epi-pen) of which program staff or mentors need to be aware, please indicate below (and by doing so, you agree that you are providing your consent for staff/mentors to take any reasonable steps required to provide any assistance required and/or to seek medical assistance in case of emergency):
Enter the code displayed
*