Mentor Sign Up Name *Email Address *Phone NumberRace/Ethnicity *American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteWould you prefer to be paired with a specific cultural community or background?YesNoIf yes to the above question, please specify the group (e.g. veterans, LGBTQ, African Americans)I identify my gender as: *Age Range *20-2526-3031-3536-4041-4546-5051-5556-6060+Preferred Method of Communication *EmailPhoneTextVideo ConferenceI am an:Occupational TherapistOccupational Therapy AssistantCurrent Primary Area of Practice *School Based PediatricsSensory Pediatric ClinicPhysical Rehabilitation, Acute CarePhysical Rehabilitation, Skilled Nursing FacilityHand TherapyMental HealthCommunity-BasedWork and IndustryAcademiaOtherIf other, please identify your area of practiceYears of Practice *0-2 years2-5 years5-10 years10+ yearsWhat type of mentorship relationship would you like to pursue? *Very short term- less than 6 monthsShort term- 6 months to one yearLong term- more than one yearWhy would you like to be a mentor?Have you provided mentorship before?YesNoWhat are your strengths? *PatientUnderstandingChallengingAssertiveKnowledgeableAccommodatingAdaptableWhat other strengths do you possess? *What is the most important strength that you look for in a mentee?What specific skills or traits are you looking for in a mentee?Do you enjoy: *ReadingSportsExerciseListening to musicTravelingCookingWhat are your other hobbies?MessageSubmit