NASP Annual Convention - Mentoring Program

Registration Form for Mentors

First Name:
Last Name:
State:
E-mail Address:
Phone Number:	(at which you can be reached during convention)

Date of Arrival:
Date of Departure:

Please provide some information on your interests and work experiences for mentees to review. (maximum of 250 characters allowed) Sample Description: I am a school psychologist in a rural public high school. My experience is in autism, bilingual issues, and RTI implementation. In my free time I write an article for my state association newsletter. Characters remaining: 250
Willing to conduct a mock job interview?	Yes No
If yes, please provide a brief description of your interviewing experience: (maximum of 250 characters allowed Characters remaining: 250

Optional
Occasionally NASP receives requests from mentors or mentees who are interested in being matched with someone from a similar background. For those participants, please provide more information about yourself (e.g., preference for a meeting with someone of the same gender, race, ethnicity, language, sexual orientation, religious background, etc.). (maximum of 250 characters allowed Sample Description: I am an African American male graduate student interested in meeting with a male, African American school psychologist preferably who works for a large, urban school district. Characters remaining: 250