Professional Mentoring Partnership Registration

* For which program(s) do you wish to volunteer? (select as many as apply) Professional Mentoring The Connector Program Career Networking Event

* Source of Referral: -- Select -- KEYS Event Brochure and Posters Employer Referred Website Radio Community Agencies Newspaper Word of Mouth

* First Name:

* Last Name:

* Street Address:

* City:

* Province:

* Postal Code:

* Phone:

Alternate Phone:

* Email:

Employer:

Job Title:

Work Address:

Work City:

Work Postal Code:

Work Phone Number:

Languages Spoken: English French

Languages Written: English French

Other:

Other:

What is the highest level of education you have achieved? -- Select -- High School Formal trade Certificate College diploma Bachelor's degree Some post-graduate studies Master's degree Doctorate degree

Please specify area of study:

Have you undergone certification in your field in Canada? -- Select -- Yes No

If yes, please specify certification type and date obtained:

Please specify the name of your profession and/or your area of expertise:

How many years of related Canadian experience do you have in your professional field? -- Select -- None Less than 1 1 to 3 3 to 5 5 to 10 Greater than 10

Please briefly describe your expectations for your participation in the KEYS Professional Mentoring Partnership:

In your opinion, what are the biggest challenges faced by immigrant professionals seeking to enter the Canadian labour market, and the Kingston labour market in particular?

For applicants to Professional Mentoring and The Connector Program only:

Are you able to meet with your mentee at work? (if applicable) -- Select -- Yes No

Volunteer References

Please specify the name and contact info for two contacts who will be willing to act as a reference on your behalf. Contacts should not be family members and should have known you in a professional capacity for at least two years.

Reference #1 Name:

Relationship to you:

Contact Phone:

Contact Email:

Reference #2 Name:

Relationship to you:

Contact Phone:

Contact Email:

Consent to Disclosure and Use of Personal Information

The personal information collected by KEYS is collected only for the purposes of effective delivery and evaluation of the Mentoring Partnership program and will not be shared for any other purpose. Information is collected for the purposes of: determining program eligibility; matching mentors and mentees; statistical reporting; outcomes follow up and evaluation; reporting to program funders. Information may be shared with program delivery partners, government funding partners, or corporate partners to ensure effective program delivery and program evaluation.

KEYS is committed to protecting the privacy of your personal information. All information provided will be held in confidence and will be protected in a manner that satisfies the requirements of applicable legislation. Your personal information will be retained in a secure manner and will be shared only for the purposes listed in the paragraph above.

* I Agree