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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.)	Yes   No
Gender
Pronouns (e.g., they/them/theirs)
Do you identify as LGBTQIA+?	Yes   No
What is your ethnic / cultural identity?
What is your citizenship status?	US Citizen   Permanent Resident   Undocumented  (DACA Status? Choose Yes No )   International   Other
What is your religion / creed (if any)?
What is your hometown?
Do you speak any languages other than English?	Yes:   No
Are you a veteran / active military?	Yes   No

Your education

The questions in this section are optional.

Were / are you a first-generation student?	Yes   No
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.)	Yes:   No
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)	Email  Phone  Text

Your application

The questions in this section are required.

Are you applying to be a mentor or mentee? (check all that apply)	Mentor  Mentee
Please note your USC Chan affiliation (check all that apply)	Current student  Prospective student (mentees only)  Faculty / staff (mentors only)  Alumni (mentors only)
As a current student, your program and expected year of graduation	Current program BS Entry-Level MA Post-Professional MA Entry-Level OTD Post-Professional OTD PhD
As a prospective Chan student, your USC Chan program of interest, current school, and expected year of graduation	Program of interest BS Post-Professional MA Entry-Level OTD Post-Professional OTD PhD
As an alumni, program you graduated from, and year of graduation	Program BS Entry-Level MA Post-Professional MA Entry-Level OTD Post-Professional OTD PhD
Are you interested primarily in occupational therapy as a clinician, or occupational science as a researcher?	OT clinician  OS researcher
How did you hear about this program?
Have you applied to be a mentor/mentee in the Chan division before?	Yes   No

About your mentorship

The questions in this section are required.

Please briefly describe any populations you’ve worked closely with and areas of practice in which you have clinical or research experience (e.g., mental health, school-based practice). Current students can list fieldwork and volunteer experience.

How has your lived experience influenced you to apply to be a mentor? Are there any specific factors/experiences that you think position you to support a mentee?

Are there any specific characteristics you are seeking in a mentee and/or are there particular populations or identities that you are passionate about working with?

What do you hope to gain by participating in this mentorship program as a mentor?

Would you be interested in mentoring more than one mentee?	Yes   No
Are you committed to contacting your mentee/s at least once per month to check in?	Yes   No

About your menteeship

The questions in this section are required.

Are there any specific areas of practice and/or populations you are interested in working with as a future occupational therapist/researcher (e.g., mental health, children diagnosed with autism)?

Are there any factors, identities, or specific lived experience that might better position a mentor to support your needs?

What do you hope to gain by participating in this mentorship program as a mentee?

Who would you prefer to have as your mentor? (check all that apply)	Current USC Chan student  USC Chan faculty / staff  USC Chan alumni
Are you committed to communicating with your mentor at least once per month?	Yes   No

Submit application

USC Chan Division of Occupational Science and Occupational Therapy
1540 Alcazar Street, CHP 133, Los Angeles, CA 90089-9003

ACOTE accreditation | NBCOT certification

The USC entry-level master’s degree program (cost of attendance) is accredited by the Accreditation Council for Occupational Therapy Education® (ACOTE®) of the American Occupational Therapy Association (AOTA). The USC entry-level doctorate in occupational therapy (OTD) degree program (cost of attendance) is accredited by ACOTE®. View our program’s ACOTE® standards public data. ACOTE® c/o the American Occupational Therapy Association, Inc.®, 7501 Wisconsin Avenue, Suite 510E, Bethesda, MD 20814, (301) 652-AOTA, www.acoteonline.org.

Professional program graduates are eligible to apply for the national certification examination administered by the National Board for Certification in Occupational Therapy, Inc.® (NBCOT®), nbcot.org. All states require licensure to practice; a felony conviction may affect a graduate’s ability to sit for the NBCOT® OTR certification examination or attain state licensure. Program results from the NBCOT® can be found online at www.nbcot.org/Educators-Folder/SchoolPerformance.