Indigenous Mentorship Registration Form for Mentors

The mentor’s role is to welcome you into the OII and University setting and help to create a sense of belonging for the mentee.

Registration Information

First Name

Last Name

Preferred Name

Program of Study

Year of Study

Student Number

Nipissing University Email Address

Address (Line 1)

Address (Line 2)

City

Province

Postal Code

Home Phone Number

Cell Phone Number

Work Phone Number

Please list any allergies/food sensitivities/dietary restrictions, etc.

EpiPen

Yes

Language(s) Spoken

Cree

Ojibway

English

French

Other…

Emergency Contact Information

First Name

Last Name

Phone Number

I give permission to Nipissing University to include my photos taken by staff, and/or occasional videotapes taken by local media. I understand these photos may be used for promotional purposes (e.g. slide show, website photo gallery, brochures, displays, advertisements, etc.), but no names will be used.

If you have any questions, please contact the Indigenous Mentorship Coordinator at indigenousmentorship@nipissingu.ca.

Protection of Privacy

The information on this form is collected under the authority of the Nipissing University Act, 1992. It is related directly to and needed by the University to support your request for Wiidooktaadwin Indigenous Mentorship activities with a community partner organization. Employees of the Wiidooktaadwin Indigenous Mentorship Department, Enji giigdoyang, Office of Indigenous Initiatives and the secondary school that you will be partnered with will use the information. If you have any questions about the collection, use, and disclosure of this information, please contact: Wiidooktaadwin Indigenous Mentorship Initiatives, Nipissing University, 100 College Drive, North Bay, ON, P1B 8L7

Indigenous Mentorship Registration Form for Mentors

Emergency Contact Information

Protection of Privacy

Students

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Faculty and Staff