Senior Mentor Program Volunteer Application

For questions about the Senior Mentor program, please contact Brenda Calhoun at 918-561-8211 or brenda.calhoun@okstate.edu.

Today's date Today's date / MM / DD YYYY
Mentorship Cycle

Mentorship Cycle Fall 2025 - Spring 2026
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email
Gender
Date of Birth Date of Birth / MM / DD YYYY
Race/Ethnicity

Race/Ethnicity African-American/Black American Indian Asian Hawaiian/Pacific Islander Hispanic White/Non-Hispanic Other Other
Marital Status

Marital Status Married Single/Never Married Divorced Widowed Other
Availability

Senior Mentors will meet with their students three times each semester, for two semesters, in the mentor's home.
Are you willing to have students in your home?

Are you willing to have students in your home? Yes No
Are you able to commit to both semesters?

Are you able to commit to both semesters? Yes No
Computer Experience

In the event we are unable to conduct in-home visits between students and mentors, visits will take place virtually over the computer (or smart phone or tablet) through Zoom, FaceTime, Google Meet, etc.
Please check all that apply:

Please check all that apply: I have a computer, tablet or smart phone capable of virtual meetings I do not have a computer, tablet or smart phone capable of virtual meetings I have used Zoom, FaceTime, or Google Meet before I have not used Zoom, FaceTime, or Google Meet
Comments:
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Special Considerations
Please indicate if any of these reside in your home so we can accommodate students with specific allergies.

Please indicate if any of these reside in your home so we can accommodate students with specific allergies. Dogs Birds Cats Smoker who smokes indoors Other
How did you hear about the Senior Mentor Program?
Any additional information you would like to share?
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Senior Mentor Program Volunteer Application

Senior Mentor Program Volunteer Application

Availability

Computer Experience

Special Considerations