Smith Renaissance Society
Mentor Request Form
This information will be shared with program staff and potential mentors.
If you would like a mentor or would like to know more about the mentor program, please complete and submit the
following part of the form. You will be invited to attend a brief Information/Orientation meeting.
Smith Renaissance Society (SRS) mentors provide friendship and guidance for SRS students; they are people who
will listen to you, help you talk through decisions, and simply provide the support of someone who has gone through
and can look back with perspective on the life passage that you are now entering.
You are not required to have a mentor in order to be eligible for the other benefits of the Smith Renaissance Society,
However, the majority of Smith Renaissance students do request mentors and find having a mentor to be rewarding.
Name
Permanent County
Phone Number
Email Address
UCSC College Affiliation
Re-entry student?
Date of birth
yes
no
Major
Expected Year of Graduation
What career possibilities interest you?
What are your hobbies or interests?
Would you be interested in having a mentor?
Would you prefer to be mentored by:
Yes
a man
No
a woman
it doesn't matter
What sort of relationship would you like with a
mentor?
How would you like your mentor to communicate
with you?
phone
personal
text
long-term
email
short-term
snail mail
A mentor or senior fellow may be able to assist you in various ways. Please respond to each item below.
Strongly
Disagree
Disagree
Neutral
Agree
Strongly Agree
Strongly
Disagree
Disagree
Neutral
Agree
Strongly Agree
I'm interested in career
advice.
I'd like career advice in a
specific field.
What specific field?
I'm interested in
participating in my
mentor's holiday
celebrations.
I might need a place to
stay during school breaks.
I might need help with
airport drop-off and pickup.
I might want help storing
belongings over the
summer.
Which of the following aspects of being mentored most interests you:
Strongly
Disagree
Disagree
Neutral
Academic support and
guidance (advice on
courses, tutoring, etc.)
General life-support (e.g.,
a place to stay during
vacations, transportation
to and from airports,
storage for belongings
during the summer, etc.)
Moral support and
encouragement – a friend
to listen and talk to
Someone to act as an
advocate when the
bureaucracy is hassling
you
Anything further we should take into consideration in seeking a mentor for you?
Please submit completed form to [email protected].
Agree
Strongly Agree