LEAP4Ed Summer Work Program Application This field is hidden when viewing the formclientidThis field is hidden when viewing the formAre 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 preferenceDate of Birth(Required) Month Day Year Language Fluency(Required) English Spanish Mandarin Chinese French Arabic Tagalog (Filipino) Vietnamese Korean Russian Portuguese Portuguese (Brazilian) Haitian Creole Other Will you be the first in your family to attend college?(Required) Yes No Your highest level of education 9th 10th 11th 12th Graduated High School & Enrolled in a Post-Secondary Education Graduated High School & Not Enrolled in a Post-Secondary Were you the first in your family to attend college?(Required) Yes No Your highest level of education GED Graduated High School Some College Associates Degree Bachelors Degree Masters Degree PHD Race / Ethnicity(Required) Hispanic or Latino White Black/African American Asian Native Hawaiian/Other Pacific Islander Choose 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 Mentee Goals and AspirationsWhat skills do you hope to build with your mentor during your mentoring relationship?(Required)Select exactly 3 choices. Career advice College Pathways Internships & first jobs Interviewing Skills Networking Non-college pathways (trade schools, certifications, etc.) Presentation skills & public speaking Professional communication (email, phone calls) What are your career interests?(Required)Select exactly 3 choices. Business, Entrepreneurship, Finance Computer Science and Coding Creative Careers (art, journalism, graphic design, photography, etc) Culinary and Hospitality Education, Human Services, Social Work Health Careers (psychology, dentistry, physical therapy, veterinary, etc) Law, Criminal Justice, Government Science, Technology, Engineering Trades (auto mechanics, construction, electrical, plumbing, etc.) This field is hidden when viewing the formWhat aspects of Healthcare are you most passionate about? Check all that apply.Select exactly 3 choices. Administration (Administrators, Health Information, Education, billing, coding, information technology, finance, compliance, marketing) Allied Health (Paramedics, Dietitians, Radiology Techs (sonography), EMTs, Occupational Health, Physical Therapy, Speech-Language Pathologists, Medical Technologists) Behavioral Health (Therapist, mental health counselor, psychopharmacologist, social worker, psychologist, psychiatrist) Clinical (Doctor, nurse, physician assistant, pharmacist, dentist, dental technician, optometrist) Patient Support (Medical Assistants, Care coordinator, community health worker, patient care navigators, enrollment, patient access coordinator) Public Health and Education (Public Health Education, Public Health Nurses, Epidemiologists) Mentor Skills and ExperienceWhat areas do you feel most confident in helping your mentee? Check all that apply.(Required) Career advice College Pathways Internships & first jobs Interviewing Skills Networking Non-college pathways (trade schools, certifications, etc.) Presentation skills & public speaking Professional communication (email, phone calls) What options best match your career field? Check all that apply.(Required) Business, Entrepreneurship, Finance Computer Science and Coding Creative Careers (art, journalism, graphic design, photography, etc) Culinary and Hospitality Education, Human Services, Social Work Health Careers (psychology, dentistry, physical therapy, veterinary, etc) Law, Criminal Justice, Government Science, Technology, Engineering Trades (auto mechanics, construction, electrical, plumbing, etc.) Of those career options selected, which is your strongest?(Required) Business, Entrepreneurship, Finance Computer Science and Coding Creative Careers (art, journalism, graphic design, photography, etc) Culinary and Hospitality Education, Human Services, Social Work Health Careers (psychology, dentistry, physical therapy, veterinary, etc) Law, Criminal Justice, Government Science, Technology, Engineering Trades (auto mechanics, construction, electrical, plumbing, etc.) This field is hidden when viewing the formWhat aspects of healthcare do you have experience in?(Required)Select exactly 3 choices. Administration (Administrators, Health Information, Education, billing, coding, information technology, finance, compliance, marketing) Allied Health (Paramedics, Dietitians, Radiology Techs (sonography), EMTs, Occupational Health, Physical Therapy, Speech-Language Pathologists, Medical Technologists) Behavioral Health (Therapist, mental health counselor, psychopharmacologist, social worker, psychologist, psychiatrist) Clinical (Doctor, nurse, physician assistant, pharmacist, dentist, dental technician, optometrist) Patient Support (Medical Assistants, Care coordinator, community health worker, patient care navigators, enrollment, patient access coordinator) Public Health and Education (Public Health Education, Public Health Nurses, Epidemiologists) This field is hidden when viewing the formDo 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 Mentee Matching PreferenceThis field is hidden when viewing the formWhich shared characteristics do you value most in your match? Please rank in order of importance by dragging.Same GenderSame RaceSame HobbiesSame Career InterestsSame Mentoring SkillsPersonality MatchingPlease select all that you think describe you.(Required) Outgoing, Energetic Analytical, Detail Oriented Dependable, Task-Focused Emotionally Intelligent, Empathetic, Sensitive Open to New Experiences, Curious Reflective, Observant Encouraging, Supportive Spontaneous, Adaptable Resilient, Calm Realistic, Practical This field is hidden when viewing the formOutgoing, Energetic(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis field is hidden when viewing the formAnalytical, Detail Oriented(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis field is hidden when viewing the formDependable, Task-Focused(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis field is hidden when viewing the formEmotionally Intelligent, Empathetic, Sensitive(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis field is hidden when viewing the formOpen to New Experiences, Curious(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis field is hidden when viewing the formReflective, Observant(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis field is hidden when viewing the formEncouraging, Supportive(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis field is hidden when viewing the formSpontaneous, Adaptable(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis field is hidden when viewing the formResilient, Calm(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis field is hidden when viewing the formRealistic, Practical(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeHow would you respond to a young person that is perpetually late to their meetings?
