Faculty / Staff Resources Student Resources
University of Southern California
University of Southern California
USC Chan Division of Occupational Science and Occupational Therapy
USC Chan Division of Occupational Science and Occupational Therapy
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About Us
About Us

Diversity Mentorship Program
Application

Use this form to apply to be a mentor, or mentee, within the USC Chan Diversity Mentorship Program. Please note that you must be at least 18 years old to participate in this program.

About you

Some people prefer mentors with shared identities, cultural backgrounds, and/or lived experiences. Answering the following demographic questions will help us to create the best possible match for each mentee request.

Please note that, aside from providing your name, and confirming that you are at least 18 years old, the questions in this section are all optional, and all information will remain confidential.

First / given name *
Last / family name *
Are you at least 18 years old? *

(You must be at least 18 to participate.)

     
Gender
Pronouns

(e.g., they/them/theirs)
Do you identify as LGBTQIA+?     
What is your ethnic / cultural identity?
What is your citizenship status?  
 
    (DACA Status? )
 
 
What is your religion / creed (if any)?
What is your hometown?
Do you speak any languages other than English?   
 
Are you a veteran / active military?     

Your education

The questions in this section are optional.

Were / are you a first-generation student?     
Were / are you a non-traditional student?

(A non-traditional student is someone who returns to school after a significant break or interruption, such as starting a family, switching careers, or serving in the military.)

   
 
Your undergraduate college / university
Your undergraduate degree and subject / major

(e.g., BA English)
Your graduate college / university
Your graduate degree and subject

(include your last graduate degree, if you have more than one)

Your contact information

The questions in this section are required.

Email address
Cellphone number
Preferred method of communication

(check all that apply)

  
 
 

Your application

The questions in this section are required.

Are you applying to be a mentor or mentee?

(check all that apply)

  
 
Please note your USC Chan affiliation

(check all that apply)

  
 
 
 
Are you interested primarily in occupational therapy as a clinician, or occupational science as a researcher?  
 
How did you hear about this program?
Have you applied to be a mentor/mentee in the Chan division before?     

Submit application