The Chair Academy : Mentor Selection Form
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Mentor Selection Form
Please fill in the information below. If you have questions concerning the form, please contact the Academy Liaison. After submitting this form, please press the "back" button on your browser toolbar to return to your class web page.

Participant Information

Your Name:
Your College (please spell out the name):

Mentor Information

(please enter the information of the mentor you have chosen)
Name: Email:
Title: College:
College Address: City, State, Zip:
Country: Province (if applicable):
Phone #: Fax #:

Additional/Replacement Mentor Information

(please enter the information of your additional mentor or add a replacement name, which means your "original" mentor is no longer serving in this role)
Name: Email:
Title: College:
College Address: City, State, Zip:
Country: Province (if applicable):
Phone #: Fax #:
Additional Mentor Replacement Mentor


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