STUDENT MENTEE APPLICATION 1
Club Can-do: LGBTQ Mentorship Program
Club Can-do is a collaborative community mentoring and student achievement
program housed at the University of North Florida LGBT Resource Center.
Program Outcomes:
Mentorship pairs will meet at four dates over the course of ten months, in addition to
opportunities for additional support. Club Can-do will accomplish the following:
1. For LGBTQIA undergraduate and graduate students: goal setting, achievement plans,
professional guidance, and personal support opportunities
2. For LGBTQIA community members: opportunities to give back and connect with up-andcoming pre-professionals through relationship building and mentorship.
3. For all participants: create cross-generational and cross-community learning, growth,
and support networks.
Club Can-do establishes a “can do!” attitude and opens up intentional, structured opportunities
for students to explore possibilities, aspirations, and pathways to achievement with a supportive,
successful mentor.
Mentee Eligibility:
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Identify as LGBTQIA (lesbian, gay, bisexual, transgender, queer, questioning, intersex,
asexual)
Enrolled at the University of North Florida and completing a degree program
(undergraduate or graduate). Other schools considered on case-by-case basis.
Live in Duval County, or other nearby county, including Nassau, St. John’s, Baker, Clay
Mentor Eligibility:


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Identify as LGBTQIA (lesbian, gay, bisexual, transgender, queer, intersex, asexual)
Live in Duval County, or other nearby county, including Nassau, St. John’s, Baker, Clay
At least 25-years-old
Model leadership and success by actively contributing time, talent, or treasure to
community organizations or initiatives
Mentorship structure and matchup:
Each mentor will be matched with one mentee. There is flexibility to make adjustments to
structure as needed (e.g.: 1:2, 1:3), but a one-to-one relationship is preferred to cultivate
emotional intimacy and trust over time. Mentors and mentees will be matched based on a variety
of factors that they will indicate on their program application, including professional and
personal interests and goals.
STUDENT MENTEE APPLICATION 2
To be considered, students and community members must complete and submit the appropriate
application via e-mail to Kaitlin Legg, Assistant Director, LGBT Resource Center, at
k.legg@unf.edu.
Questions? Contact Kaitlin Legg at 904-620-2939.
Mentee/Student Application
N#______________________
Date:___________________
Please attach an up-to-date resume that includes professional and volunteer experience.
Background Information:
Preferred Name:
Legal Name:
First: ________________________ (MI) _______ Last: _______________________
Physical Address:
Street: ______________________ City: __________________ State: ______
Zip code: ________
Phone #_________________ Email Address: ___________________________________
Date of Birth: _____/____/______ Age: _____
Classification:
o Freshmen
o Sophomore
o Junior
o Senior
o Graduate (masters or doctoral)
Please list your major and minor (if applicable):___________________________
What organizations, activities, sports, clubs, etc. are you currently/or have been involved
in?
What language(s) do you speak fluently?
STUDENT MENTEE APPLICATION 3
What careers or professions are you interested in?
How will you personally and professionally benefit from having a mentor?
In regard to your identity and expression, please MARK all that apply:
o
o
o
o
o
o
o
Lesbian
Gay
Bisexual
Transgender
Queer
Asexual
Cisgender
o
o
o
o
o
o
Genderqueer
Female
Male
Intersex
Religious
Nonreligious
What gender pronouns do you use (check all that apply)?
o
o
o
o
He, him, his
She, her, hers
They, them, their
Other:_______________________
Race and ethnicity (check all that apply):
o
o
o
o
o
o
o
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Hispanic or Latino
Other _____________________________
STUDENT MENTEE APPLICATION 4
Do you have a disability that requires reasonable accommodations? If so, please provide
information about accommodations below:
On a scale of 1 to 5, where 1 is least likely and 5 is most likely, how would you rate the
following characteristics in regard to your personality?
1
2
3
4
5
Quiet
Adventurous
Outgoing
Withdrawn
Inquisitive
Insecure
Nervous
Friendly
Spiritual
Confident
Sensitive
Shy
Happy
Moody
Talkative
On a scale of 1 to 7, where 1 is least important and 5 is most important, how would you rate
the importance of the following identities that pertain to you?
1
2
3
4
5
Gender Expression
Gender Identity
Sexual Orientation
Race/Ethnicity
Religious/nonreligious
identity
Socioeconomic status
Is there anything else that you would like to be taken into consideration with this
application? Please share below.
STUDENT MENTEE APPLICATION 5
Personal Information:
It is important that we know your experience with expressing your gender and sexual orientation
with others to facilitate an effective mentoring relationship. Please complete the following table
by checking the appropriate box:
Never
Rarely
Openly express gender to
friends/acquaintances
Openly express sexuality
to friends/acquaintances
Openly talk to family
members about gender
Openly talk to family
members about sexuality
Openly talk to new people
about gender
Openly talk to people
about sexuality
Experience discrimination
from family members
Experience discrimination
from new people
Experience discrimination
from peers
Experience discrimination
from the general public
Please Mark all that apply:
o
o
o
o
o
o
Closeted about gender identity
Closeted about sexual orientation
Out to one or few people about gender identity
Out to one or few people about sexual orientation
Out to most people about gender identity
Out to most people about sexual orientation
Other (please specify)________________________
Occasionally
Frequently
STUDENT MENTEE APPLICATION 6
Consent Form
As a potential mentee:
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


I meet all mentee requirements for this program:
o Identify as LGBTQIA (lesbian, gay, bisexual, transgender, queer, questioning,
intersex, asexual)
o Enrolled as an undergraduate or graduate student. Other schools considered on
case-by-case basis.
o Live in Duval or surrounding counties, such as Nassau, St. John’s, Baker, or
Clay
I understand that I am not obligated to participate in this program.
I understand that my mentor will not serve as a counselor or therapist, but will support
my educational experience and professional and personal goals.
I have the right to share personal information at my discretion.
I have the right to discontinue participating in this program at any time.
_____________________________
Print Name
______________________________
Signature
______________________________
Date
Received by:
Kaitlin Legg
Assistant Director
Name
Title
2015
Signature
Date
If you may have any questions in regard to this program and/or application, please contact:
Kaitlin Legg, Assistant Director, UNF LGBT Resource Center at k.legg@unf.edu or (904) 6202939.