Mentor Application *- required fields Mentor Application * Your Name: Your Address: Your Phone Number: * Your Email: Date of Birth: Age: Gender Identity: Gender Expression: Sexual Orientation: Race/Ethnicity: International Student/Staff/Faculty Yes No Country of Origin: Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Icel And India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Dem People'S Republic Korea, Republic Of Kuwait Kyrgyzstan Lao People'S Dem Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Ant Illes New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint K Itts And Nevis Saint Lucia Saint Vincent, The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia , S Sandwich Is. Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard, Jan Mayen Islands Sw Aziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Is. Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (US) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Language(s) Spoken Fluently Religious/Spiritual Ideology Affiliation to UW: UW Undergrad Student UW Grad Student UW Alum UW Staff/Faculty UW Grad Year: Areas of Study: Current Employer & Job Title (if applicable): Future Career Interests: How did you hear about the Queer Mentoring Program? Why do you want to be a mentor in the Queer Mentoring Program? What experience(s) have you had working with college students? What are some of your interests and activities on and off campus? What involvement do you have with the queer community? Please check all that apply. Queer Relationship Q Center Campus Organization Discussion Group Volunteer with Community Organization/Group Other None Please Describe Your Above Involvement: Is there anything else you would like us to know about you that will help us make a good match?