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VAPLP Mentor Form
Mentor Application
This application will be used to match mentees with a mentor for the upcoming pod of VAPLP. Please complete the entire form. Due to the limited number of participants, not all applicants will be selected as mentors. Your responses will be public-facing to this year’s participants. This application has three sections: (1) General Information (2) Leadership Experience & Expertise (3) Mentor & Mentee Relationship.
Name
(Required)
First
Last
Pronouns
(Required)
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
If you are a VAPLP alum, which cohort/pod did you participate in?
Cohort 1
Cohort 2
Cohort 3
Cohort 4
Cohort 5
Cohort 6
Cohort 7
Pod 8
Please describe your race/ethnicity (check all that apply)
(Required)
Native or First Nation (e.g., Rappahannock Tribe, Monacan Indian Nation, Pamunkey, Traditional Gov’t., etc.)
Asian or Asian American (e.g., Chinese, Japanese, Filipino, Korean, Pakistani, Sri Lankan, Vietnamese, etc.)
Black, African, or African American (e.g., Jamaican, Nigerian, Haitian, Ethiopian, etc.)
Hispanic or Latino/a/x (e.g., Puerto Rican, Mexican, Cuban, Salvadoran, Colombian, etc.)
Middle Eastern or North African (e.g., Lebanese, Iranian, Egyptian, Moroccan, Palestinian, etc.)
Native Hawai’ian or Pacific Islander (e.g., Samoan, Guamanian, Chamorro, Tongan, etc.)
White or European (e.g., German, Irish, English, Italian, Polish, French, etc.)
How would you describe your gender identity? (check all that apply)
(Required)
Woman
Man
Transgender
Nonbinary
Two-Spirit
How would you describe your sexual orientation? (check all that apply)
(Required)
Lesbian
Gay
Bisexual
Queer
Pansexual
Asexual
Straight or heterosexual
I am not sure
Prefer not to say
Current Occupation and Employer
(Required)
Please upload a photo of yourself that you're comfortable being shared.
(Required)
Max. file size: 50 MB.
Leadership Experience
Please list your past & present community involvement as it relates to the role of a mentor with VAPLP.
Please describe any past experiences you have being a mentor or mentee.
Which of the following best describes you & your work?
(Required)
Community Organizing (issue-based)
Political Campaigns
Government
Nonprofit Advocacy
Nonprofit Direct Services
Funding/Fundraising
Other
What is your focus area/s? (check all that apply)
(Required)
We know much work gets done at the intersections of multiple issues, so please select as many as you closely work with.
Arts + culture
Advocacy
Civil rights
Climate + environment
Community
Data
Economic Justice
Education
Elections
Empowerment
Faith-based
Immigration
Justice Reform
Health
Housing + Poverty
Leadership Development
LGBTQ+
Racial Justice
Voting + voters
Workers’ Rights
Youth
Mentor + Mentee Relationship
What does mentorship mean to you?
(Required)
Fun Fact
(Required)
Share a lil tidbit about you as a human aside from your work.
Anything else?
Time Commitment Agreement
I confirm that I can commit to the virtual and in-person meetings detailed below. (If it is outside your capacity but you are still interested, please detail what barriers there are in “Anything else?”)
– Mentor Orientation | virtual | May 3rd or 4th, 2pm-3:30pm (choose one date)
– Reveal + Mentee Meeting 1 | in-person, Leesburg | Saturday, May 20th, 12pm – 3:30pm
– Mentee Meeting 2 | virtual | May 22nd – June 22nd
– VCET Check-in | virtual | June 26th – July 27th
– Mentee Meeting 3 | virtual | June 26th – July 27th
– Mentee Meeting 4 | virtual | July 31st – August 24th
– VAPLP Graduation | in-person, Richmond | Saturday, August 26th, 1pm – 4pm
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