LEAP for Education Matching Form This field is hidden when viewing the formclientidAre you a Mentor or a Mentee?(Required) Mentee Mentor Name(Required) First Last Phone(Required)Email(Required) Gender(Required)MaleFemaleTrans MaleTrans FemaleGender NonconformingI prefer not to shareOtherPronounshe/him/hisshe/her/hersthey/them/theirsey/em/eirzie/zim/zerNo preferenceAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required) Month Day Year Age(Required)15161718192021222324College / University AttendedWhat is your current employment status? Employed Retired Unemployed Student Other College or UniversityCompany Name, Job TitleFormer Company, Job TitleSpecifyLanguage Fluency(Required)Select between 1 and 3 choices. English Spanish Mandarin Chinese French Standard Arabic Tagalog (Filipino) Vietnamese Korean Russian Portuguese Portuguese (Brazilian) Haitian Creole Other Race / Ethnicity(Required) Hispanic or Latino White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian or Alaskan Native American Indian/Alaskan Native & Black/African Am. Other Multi-Racial Language Fluency(Required)Select between 1 and 3 choices. English Spanish Mandarin Chinese French Standard Arabic Tagalog (Filipino) Vietnamese Korean Russian Portuguese Portuguese (Brazilian) Haitian Creole Kumar Arabic Other Race / Ethnicity Hispanic or Latino White Black/African American Asian Native Hawaiian/Other Pacific Islander Middle Eastern American Indian or Alaskan Native American Indian/Alaskan Native & Black/African Am. Other Multi-Racial Prefer not to say Will you be the first in your family to attend college?(Required) Yes No Highest level of education(Required)9th10th11th12thGraduated High School & Enrolled in a Post-Secondary EducationGraduated High School & Not Enrolled in a Post-SecondaryWere you the first in your family to attend college?(Required) Yes No Highest level of education(Required)GEDGraduated High SchoolSome CollegeAssociates DegreeBachelors DegreeMasters DegreePHDWhat grade will you be entering in the Fall of 2025?(Required)10th11th12thChoose all the hobbies that interest you.(Required) Animal Care Arts and Crafts Automobiles Podcasting/Social Media Cooking/Food Cosmetology Dance Exercise Film/Photography Gaming Gardening Meditation/Yoga Music Reading Sports Travel Volunteering Woodworking Writing What skills do you hope to build with your mentor during your mentoring relationship? Please rank your top three in order of importance by dragging.Career adviceCollege PathwaysInternships & first jobsMock interviewingNetworkingNon-college pathways (trade schools, certifications, etc.)Presentation skills & public speakingProfessional communication (email, phone calls)What areas do you feel most confident in helping your mentee? Please rank your top three in order of importance by dragging.Career adviceCollege PathwaysInternships & first jobsMock interviewingNetworkingNon-college pathways (trade schools, certifications, etc.)Presentation skills & public speakingProfessional communication (email, phone calls)What skills do you hope to build with your mentor during your mentoring relationship? Please rank your top three in order of importance by dragging.Leadership and TeambuildingHealthcare insightsEmpathy and CommunicationSoft SkillsCritical ThinkingHealth System ManagementHealthcare TechnologyHealthy Behaviors & HabitsBuilding ConnectionsCareer GoalsAcademic SuccessWhat skills are you able to mentor in? Please rank your top three in order of importance by dragging.Leadership and TeambuildingHealthcare insightsEmpathy and CommunicationSoft SkillsCritical ThinkingHealth System ManagementHealthcare TechnologyHealthy Behaviors & HabitsBuilding ConnectionsCareer GoalsAcademic SuccessWhat are your career interests? Please rank your top three in order of importance by dragging.Business, Entrepreneurship, FinanceComputer Science and CodingCreative Careers (art, journalism, graphic design, photography, etc)Culinary and HospitalityEducation, Human Services, Social WorkHealth Careers (psychology, dentistry, physical therapy, veterinary, etc)Law, Criminal Justice, GovernmentScience, Technology, EngineeringTrades (auto mechanics, construction, electrical, plumbing, etc.)What options best match your career field? Please rank your top three in order of importance by dragging.Business, Entrepreneurship, FinanceComputer Science and CodingCreative Careers (art, journalism, graphic design, photography, etc)Culinary and HospitalityEducation, Human Services, Social WorkHealth Careers (psychology, dentistry, physical therapy, veterinary, etc)Law, Criminal Justice, GovernmentScience, Technology, EngineeringTrades (auto mechanics, construction, electrical, plumbing, etc.)What aspects of Healthcare are you most passionate about? Please rank your top three in order of importance by dragging.Public Health and Education (Public Health Education, Public Health Nurses, Epidemiologists)Patient Care (Medical Assistants, CNAs, Nurses, Patient Advocates or Healthcare Navigator)Support Roles (Medical billing and coding, Chaplains/Rabbis/Monks/Imam, Information Technology, Finance)Administration and Management (Administrators, Health Information Managers, Education)Clinical (Doctor, Nurse, Physician Assistant, Pharmacist, Dentist)Allied Health (Paramedics, Dietitians, Radiology Techs (sonography), EMTs, Occupational Health, Physical Therapy, Speech-Language Pathologists, Medical Technologists)Medical Research (clinical research coordinators, PhDs)Biomedical EngineeringWhat aspects of healthcare do you have experience in? Please rank your top three in order of importance by dragging.Public Health and Education (Public Health Education, Public Health Nurses, Epidemiologists)Patient Care (Medical Assistants, CNAs, Nurses, Patient Advocates or Healthcare Navigator)Support Roles (Medical billing and coding, Chaplains/Rabbis/Monks/Imam, Information Technology, Finance)Administration and Management (Administrators, Health Information Managers, Education)Clinical (Doctor, Nurse, Physician Assistant, Pharmacist, Dentist)Allied Health (Paramedics, Dietitians, Radiology Techs (sonography), EMTs, Occupational Health, Physical Therapy, Speech-Language Pathologists, Medical Technologists)Medical Research (clinical research coordinators, PhDs)Biomedical EngineeringWhat would you like your first job to be and why?(Required)Do you have experience in a helping profession? (Teacher, Nurse, Therapist, Social Worker, etc.)(Required) Yes No Do you have experience as a mentor in a mentoring program?(Required) Yes No Have you mentored with LEAP’s Summer Work Program before? No Yes, for 1 Summer Yes, for 2 Summers Yes, for 3 Summers Yes, for 4+ Summers Personality MatchingWhich shared characteristics do you value most in your match? Please rank in order of importance by dragging.Same GenderSame RaceSame HobbiesSame Career InterestsSame Mentoring SkillsPreferred way to meet? Virtual In-Person By Phone Here are a number of personality traits that may or may not apply to you. Please select a response for each statement to indicate the degree to which you agree or disagree. You should rate the extent to which the pair of traits apply to you, even if one characteristic applies more strongly than the other.Outgoing, Energetic(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeAnalytical, Detail Oriented(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeDependable, Task-Focused(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeEmotionally Intelligent, Empathetic, Sensitive(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeOpen to New Experiences, Curious(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeReflective, Observant(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeEncouraging, Supportive(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeSpontaneous, Adaptable(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeResilient, Calm(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeRealistic, Practical(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeHow would you respond to a young person that is perpetually late to their meetings?
