First Name *

Last Name *

Preferred First Name (optional)

Pronouns *

Another

Cell Phone *

Email *

Race/Ethnicity (select all that apply) *

Asian Middle-Eastern Black / African-American / Caribbean-American / African Hispanic / LatinX Native American / American Indian / Native Alaskan / Pacific Islander White / Caucasian / European Another racial identity Choose not to respond

If another, please specify:

These next two questions are optional to answer. These questions help us with the matching process along with end of year reporting.

Gender:

My gender is:

Are you transgender:

If you speak a language other than English, please include it here:

Please indicate which of these identities apply to you, if any:

First Generation (those whose parents' highest level of education is a high school diploma or less) Low Income (an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount) Person with a disability LGBTQIA+

Current employer *

Employer Address *

State *

City *

Zip *

Title/Position *

Years in Position *

Please give a short description of your job responsibilities *

Are you a member of BAMIT or LAMIT? *

My employer (government or a lab with security clearance) has performed a background check: *

College *

Major *

Degree Received *

Do you have a master's degree? *

If yes, what school is your master's degree from?

What is the subject of your master's? *

Do you have a terminal degree? *

If yes, where is your degree from?

What is the subject of your terminal degree? *

Area of Expertise or Research Specialty *

Please rate which areas of protégé professional development you are most comfortable and interested in supporting. 1 being most comfortable and interested *

1 -

2 -

3 -

4 -

5 -

What are your areas of expertise you could share with a protégé? *

How many years of mentoring experience do you have? *

Please create and confirm your account password for future login:
(Your Username will be your Email)

Password _{must be between
8 and 20 characters}

Confirm Password

E-Mentoring Mentor Advocate Partnership Program
Participation Agreement

The Massachusetts Institute of Technology Office of Minority Education (OME) appreciates your willingness to participate in the E-Mentoring Mentor Advocate Partnership Program (EMAP). OME promotes respect and responsibility for protégés, mentors, IACME partners, staff and other stakeholders. As such, it is crucial that a safe and respectful environment is established for both protégés and mentors.

All EMAP Program participants are expected to read, adhere to and sign below acknowledging their commitment to fulfilling program expectations. By participating in EMAP, I commit to:

Program Expectations

Connecting with my Mentor/Protégé once every month, from September 2024 to May 2025. Being proactive with scheduling monthly interactions and also promptly responding to communication
Submitting monthly online check-in forms, from September 2024 to May 2025
Engaging Office of Minority Education EMAP program staff as needed
Attending End of Year Celebration event (if available)
Submitting End of Year survey
Abstaining from conduct considered improper and inappropriate. The prohibited conduct that is listed below is not an exhaustive list, as we cannot, with foresight, determine inappropriate conduct under every circumstance. Moreover, we do not limit the right to discharge participants for conduct that is not listed below.
- Knowingly disseminate or transmit content that is unlawful, harmful, threatening, abusive, harassing, tortuous, libelous, pornographic or invasive of another’s privacy
- Knowingly disseminate or transmit content that infringes on any patent, trademark, trade secret, copyright or other proprietary rights of any other party
- Knowingly disseminate or transmit any unauthorized advertising, promotional materials and goods, chain letters, spam, junk mail, or any other type of mass unsolicited email to others who have not agreed to receive such materials
- Impersonate another person or entity
- Stalk or harass another protégé or mentor
- Knowingly disseminate, transmit or make otherwise available any materials that contain software viruses, computer code, files or programs designed to interrupt, destroy or limit the functionality of any computer software or hardware
- Collect or store personal data about other protégés or mentors
- Knowingly disseminate or transmit illegal and illegally-obtained materials
- Fraternize outside of the professional mentor and protégé relationship
- Share confidential information

I agree to the code of conduct and to fulfill the EMAP program expectations listed above for the 2024-2025 session

EMAP - 2024-2025 SESSION

Mentor Application

CONTACT

INFORMATION

EMPLOYMENT

EDUCATION

MENTORING

MENTORING AGREEMENT

E-Mentoring Mentor Advocate Partnership Program
Participation Agreement

EMAP - 2024-2025 SESSION

Mentor Application

CONTACT

INFORMATION

EMPLOYMENT

EDUCATION

MENTORING

MENTORING AGREEMENT

E-Mentoring Mentor Advocate Partnership ProgramParticipation Agreement

E-Mentoring Mentor Advocate Partnership Program
Participation Agreement