Basic Information

Full Name

Email Address

Phone Number

City

State

Affiliation to Institution:

Current Student

Alumni

Faculty/Staff

Professional (Non-Affiliated)

Other: (Short answer)

Institution Name (if applicable):

Interests and Goals

What is your primary goal in participating in Bridge the Yard? (Paragraph response)

What areas of mentorship or collaboration are you interested in?

Career Development

Academic Support

Community Engagement

Leadership Development

Networking Opportunities

Other: (Short answer)

Are you seeking mentorship or offering to mentor?

Seeking Mentorship

Offering to Mentor

Both

What skills, expertise, or experience can you contribute to the program (if mentoring)? (Paragraph response

Availability and Commitment

How much time can you commit to the program?

1-2 hours per month

3-5 hours per month

More than 5 hours per month

Consent and Submission

I agree to allow Bridge the Yard and its partners to contact me regarding this program and related opportunities.

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