MENTOR APPLICATION 1
Club Can-do: LGBTQIA 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.
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. Younger applicants considered on case-by-case basis.
Model leadership and success by actively contributing time, talent, or treasure to
community organizations or initiatives
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
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.
MENTOR 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
Mentor Application
Date:___________________
Please attach an up-to-date resume with education, professional and volunteer experience.
Background and Demographic Information:
Preferred Name:
Legal Name:
First: ________________________ (MI) _______ Last: _______________________
Address:
Street: ______________________ City: __________________ State: ______
Zip code: ________
Phone #______________________ Email Address: ___________________________________
Date of Birth: _____/____/______
Time commitment (circle one):
One Year
Two Year
Please designate commitment based on your preference and availability. At the end of the
program year, mentors and mentees may mutually decide to either remain in contact or end the
relationship.
Do you have previous experience, informal or formal, as a mentor? If so, please describe:
MENTOR APPLICATION 3
Please briefly state what mentorship means to you and how you can utilize your skills and
experiences to succeed at mentoring LGBTQIA students:
Please list any additional information that you would like us to consider or know:
What language(s) do you speak fluently?
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
MENTOR APPLICATION 4
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 White
o Hispanic or Latino
o Other:______________________
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
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
Quiet
Adventurous
Outgoing
Withdrawn
Inquisitive
Insecure
Nervous
Friendly
Spiritual
Confident
Sensitive
Shy
Happy
Moody
Talkative
2
3
4
5
MENTOR APPLICATION 5
On a scale of 1 to 5, 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
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 check the appropriate boxes:
Never
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
Rarely
Occasionally
Frequently
MENTOR APPLICATION 6
Consent Form
As a potential mentor:
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I meet all mentor requirements for this program:
o Identify as LGBTQ (lesbian, gay, bisexual, transgender, queer)
o At least 25-years-old. Younger applicants considered on case-by-case basis.
o Living in Duval or surrounding counties, including Nassau, St. John’s, Baker,
Clay)
o Model leadership and success by actively contributing time, talent, or treasure to
community organizations or initiatives
I understand that I am not obligated to participate in this program.
I have the right to share personal information at my discretion.
I have the right to discontinue participating in this program at any time.
I understand that I will not be compensated for my mentoring services and that this
opportunity is for volunteer purposes.
_____________________________
Print Name
______________________________
Signature
______________________________
Date
Received by:
Kaitlin Legg
Assistant Director
Name
Title
2015
Signature
Date
Accepted mentors will be contacted to complete a background check at no cost to them.
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.