Spring 2020 Collective Success Network Mentor Application Form
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Pod Program Description
Thank you for your interest in joining the Collective Success Network pod mentorship program.

The pod mentorship program consists of 2 professionals and 4-6 students meeting for 5 guided pod sessions (2 hours each) about every other week during the academic semester. During this time a range of relevant topics will be discussed to help your mentees through their college experience and future professional journeys.

It is important to know your background so that we can match you with the pod and co-mentor that may be the best fit for you.

The application process consists of completing this survey and a follow-up phone conversation (20 minutes). Upon selection into the program, you are expected to attend a MANDATORY orientation session (3 hours) on February 15, 2020 from 1-4 pm at 3675 Market St and 5 pod sessions (2 hours each).
General Contact Information
Share your contact information so we can know the best ways to reach you
First Name *
Last Name *
Email Address *
Mobile Phone Number *
Home Phone Number
What is your current city and state of residence? *
What is your preferred gender identity? *
What year were you born? *
What ethnicity do you identify with? *
Required
What college did you attend for undergraduate studies? *
What was your field(s) of study for undergraduate? *
Do you have a higher degree? If yes, please share where you went to college for your higher degree.
If you have a higher degree, what degree did you get?
What career fields have you worked in and/or can you provide perspective on? (check all that apply) *
Required
What company/organization do you currently work for? *
How would you describe your role at your current organization? *
How did you hear about the Collective Success Network?
Clear selection
Would you be willing to be part of the CSN database to be a resource to students who are interested in learning more about your company or field(s) of work? (Only your name, current company of employment, role, professional field(s), and contact information) would be shared). *
Do you have any food allergy or dietary restrictions? *
If you do have any food allergy or dietary restriction please describe
Professional or Personal Reference #1: Name *
Professional or Personal Reference #1: Contact information (email or phone number) *
Professional or Personal Reference #1: Relationship to you *
Professional or Personal Reference #2: Name *
Professional or Personal Reference #2: Contact information (email or phone number) *
Professional or Personal Reference #2: Relationship to you *
Background Information
Share your background information for pod and mentee matching purposes
Hometown *
Occupation *
Position/Title *
Do you identify as: *
Have you been in a mentorship program previously? If you have, please specify the program. *
Please share any insights from your previous mentorship program.
What makes you want to be part of Collective Success? *
What are the 3 reasons for your interest in being a mentor? *
Are there challenges you anticipate in your role as mentor that you would like to see addressed during mentor orientation/training? *
Are you available for one-on-one meetings outside of the five mandatory sessions? *
What 2 hour windows are you available to meet with your pod? (check all that apply) *
Required
Optional: if there is a mentor that you would like to be paired with, please share their name here.
If you work in Center City or University City would you prefer to:
Clear selection
Based on student feedback, we are also piloting a one on one mentoring program this semester. Would you be interested in participating in this program in addition to or instead of the Pod program?
Clear selection
Does your company have any connections/partnerships with coop programs or internships? *
Have you ever been convicted of a felony/misdemeanor? *
Are you under current indictment? *
For applicants not associated with sponsor company (PECO, Comcast, or RSM): Are you willing to take and able to pay for a criminal history background check? *
Were you referred to the CSN mentorship program by a previous participating mentee or mentor? If yes, please share their name so they can be entered into a lottery for a cool prize!
Anything else you would like us to know?
If you have a LinkedIn Profile, please share the page here:
By completing this application, I understand that the next step is a follow-up phone conversation (20 minutes). Upon selection into the program, I am committed to a mentor orientation session (3 hours) and 5 pod meetings (2 hours each, approximately every other week) during the academic semester. Failure to participate may result in being removed from the program.                             *
Thank you for completing the mentor application! We look forward to meeting you at a Collective Success event.
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