JC Mentor Application

Thank you for your interest in applying to the Johnson City Mentor Program. You MUST complete ALL questions on this form in order to be considered.

Last Name______First Name______

  1. What is your current class year at Binghamton University?
    You have to have completed one year of college prior to applying to the JC Mentor Program and this program is for undergraduate students only.

_____Rising Sophomore _____Rising Junior _____Rising Senior

  1. What are your interests or hobbies?
    JC School Staff use answers to this question to match you with a mentee who has similar interests.
  1. What, if any, other outside commitments or obligations do you have during the semester? Examples include: part-time job, clubs, athletics, leadership roles, etc...
  1. Why are you interested in becoming a mentor to a middle school student? What do you hope to accomplish in your mentoring relationship?
    This is a short answer essay question. Please give the JC School Staff some context about your interest and who you are as a person.
  1. Why are you an ideal candidate for this program?

In paragraph form, present a few experiences you have had and skills you possess that prepare you to mentor a student.

  1. I am aware that participation in the JC Mentor Program involves 5 hours in the JC School each week and a 1-hour weekly seminar on BU's campus and I can make that commitment to a Johnson City Middle School student.If you select "No," you will not be considered an applicant for the program and will not be selected to interview. Please highlight your response.
  1. Do you need to petition to overload to participate in the JC program which awards two internship credits?
    If no, there is no further action you need to take. If yes, YOU MUST receive approval from your College (Harpur, Watson, CCPA, SOM, Decker) before the interview. If you are not approved you may not participate in the program.
  2. Are you an international student?
    If yes, you may need to apply for a CPT. Please speak to ISSS to process any necessary paperwork prior.
  1. I understand that the hours at the JC Middle School are generally 7:30 am-2:15 pm and that I must complete the five hours per week during this time.If you select "No" you will not be selected to interview.

Please give your consent by agreeing with signature to the statement below.

Under the provisions of the Family Education Rights and Privacy Act, I authorize the Student Conduct Officer to provide documentation and discuss all information related to any Student Conduct Review, for the purpose of determining my participation in the JC Mentor Program.

Signature______Date______

Please note that a previous or current student conduct record will not disqualify you from the program.

Binghamton's Fleishman Center staff manages the application process. If you have any questions as you complete this form, please contact Lexie Avery at for assistance.