Shippensburg University - Mentor Submission Form

What is the name you go by?

Pronouns:

What is your student/staff email? (If you are an alum and do not have access to a Ship email any longer, please put your personal email.)

What is your student/staff ID? (This is only used to verify that you are a Shippensburg University student. If you are an alum and do not have your ID any longer, please write "alum".)

What is your gender identity? (If you have multiple gender identities, feel free to put them all or what you feel comfortable sharing. If you do not have a gender, feel free to write N/A.)

What is your sexual orientation? (Sexual orientation refers to how you identify your attractions to other people. If you are asexual, feel free to write asexual or to write N/A if desired.)

What is your romantic orientation? (Some people, including asexual folks, may be romantically attracted to people while they are not necessarily sexually attracted to people. Others may, for example, identify as heterosexual but feel that they are romantically attracted to all genders and identify as biromantic. If this question does not apply to you, feel free to write N/A. If you are aromantic, feel free to write aromantic or N/A if desired.)

What is your race/ethnicity? (If you are an Indigenous person, you may write Indigenous, the name of your nation(s), or N/A if desired).

If you are a student, what year are you in school? (If you are a transfer student, please select transfer student and the year. If you are not a student, you do not need to respond.)

First Year

Second Year

Third Year

Fourth Year+

Transfer Student

Graduate Student

How old are you?

Do you have any accommodation needs for this program to work for you? (For example, do you need access to sign language interpreters, braille forms, translators for languages other than English, and/or a mentee that speaks/signs a language other than English or ASL?) Please explain.

Why do you want to be a mentor? What do you feel you can offer LGBTQIA students in terms of academic, professional, and/or personal support? Do you feel you have the capacity to provide students support in navigating gendered, sexualized, racialized experiences and spaces? If you feel that you can, for example, provide support vis-a-vis navigating gendered experiences and spaces but not sexualized and/or racialized experiences and spaces, please note that.

In submitting this form, I consent to the Pride Center staff having access to my answers in order to match me with a well fitting mentor. I consent to the Pride Center using my demographic data (e.g. gender, race, ethnicity, sexual orientation) to assess who is using the center, with the understanding that this data will be disconnected from my name, email, ID and anything else that could identify who I am to others. I consent to the Pride Center emailing me in order to arrange a time to meet with the Pride Center director and my potential mentor.

I agree.

I do not agree.

I would like to be contacted further by the Pride Center to discuss this.

I understand that this program is meant to be utilized as a way for students to further their identity, academic, and professional development and to foster holistic growth. I understand that this program is not meant to be used for romantic/sexual purposes. I understand that my mentee and I will agree upon set boundaries around when and where we meet and what we discuss and that violating those boundaries will be considered an abuse of the mentoring program. I understand that I, as a mentor, have a responsibility to alert the Pride Center staff to any unethical, harmful, or otherwise problematic behavior occurring through this program. I understand that mentor/mentee program participation can end if the Pride Center staff feel that the program is being abused or are alerted to anything unsafe occurring.

I agree.

I do not agree.

I would like to be contacted by the Pride Center to discuss this further.

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Mentor Submission Form

Mentor Submission Form

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