N4A Mentor Program - Mentor Form

Name:	Date:
Job Title:
Institution:	Size of Institution:
N4A Region:
Work Address:
Work Phone:	E-mail Address:
Main Responsibilities:
To better assist us in matching you with a mentee, please tell us a little about yourself:
Gender:	Ethnicity:
Division: NCAA Div. I NCAA Div. II NCAA Div. III Junior College NAIA Other , Please Specify:
How many years have you been in Academic Athletic Support?
Special Interests:
Please tell us a little about the individual you would like to be matched with:
Specific Person:
OR
Gender: No Preference	Ethnicity: No Preference
Division: NCAA Div. I NCAA Div. II NCAA Div. III Junior College NAIA No Preference
Would you be willing to mentor a new professional or graduate student from outside your region?

If you have any questions, comments, or concerns, please contact:

Martina Martin
N4A Mentor Program Coordinator
University of Kentucky
Memorial Coliseum
Lexington, KY 40506-0019
Office: (859)257-6944
Fax: (859)257-7794
mamart3@email.uky.edu