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2017/2018 Science Club Mentor Application

This application is for the Winter quarter (January 2018-March 2018) of Science Club at one of the following four sites:

- Pedersen-McCormick Boys & Girls Club: 4835 N Sheridan Rd, Chicago, IL 60640
Times: Monday, Wednesday or Thursday 4:00-5:30pm

- TrueValue Boys & Girls Club: 2950 West 25th Street, Chicago, IL 60623
Times: Tuesday or Thursday 5:00-6:30pm

- Family Focus: 2010 Dewey Ave, Evanston, IL 60201
Time: Thursday 5:00-6:00pm

- NEW! MetaMedia at the YMCA: 1000 Grove St., Evanston, IL 60201
Time: Wednesday 5:00pm-6:30pm

Science Club mentorship is open to STEM graduate students, staff, and postdoctoral fellows. We are not taking applications from undergraduate students at this time. Also, please note that Science Club is a long term commitment. We ask that mentors commit to 3 quarters or 2 semesters (1 academic year)

Instructions: Please fill out the form below. Note that the form must be filled out in one session and you cannot return to it at a later date. Once we receive your information, you will be contacted for a brief interview.

**Please note, Northwestern graduate students from DGP, NUIN and/or IBIS are not eligible to participate in Science Club until they have completed their comprehensive exams.

If you have any questions or concerns, please contact Emily Mathews at emily.mathews@northwestern.edu or Ashley Jennings at ashley.jennings@northwestern.edu

7. Where do you work? *This question is required.
Are you primarily based on Northwestern's Evanston or Chicago campus?
8. What is your position? *This question is required.
9. How many years have you been in this position? *This question is required.
Which of these programs do you work in?
Which of these programs do you work in?
Which of these programs do you work in?
13. Where would you prefer to volunteer as a mentor? (Check all possible options) *This question is required.
For Sept 2017 - June 2018, please check the days of the week that you will be available to mentor for Science Club after 3:30pm? *This question is required.
For Sept 2017 - June 2018, please check the days of the week that you will be available to mentor for Science Club after 3:30pm? *This question is required.
For Sept 2017 - June 2018, please check the days of the week that you will be available to mentor for Science Club after 4:30pm? *This question is required.
For Sept 2017 - June 2018, please check the days of the week that you will be available to mentor for Science Club after 4:30pm? *This question is required.
For Sept 2017 - June 2018, please check the days of the week that you will be available to mentor for Science Club? *This question is required.
For Sept 2017 - June 2018, please check the days of the week that you will be available to mentor for Science Club? *This question is required.
For Sept 2017 - June 2018, please check the days of the week that you will be available to mentor for Science Club after 4:30pm? *This question is required.
16. Ethnicity
17. Race (Check all that apply)