* Required Fields
Mentor Information
* First Name 
* Last Name 
* Birth Date 
* Gender 
* T-Shirt Size 

Contact Information
* Email 
* Cell Phone 
* Address 
* City 
* State 
* Zip 

School Information
* Grade/Year 
* High School 
* College/University 

Past Code to Success Experience
If you previously attended Code to Success, please indicate your campus, the year attended, and if you were a graduate.  

* Year 
* Campus 
* Graduate 

Position and Availability
* Type of Mentor 

For University Mentors - Please select Not Applicable in the Hours per Week drop down below.

For Peer Mentors - Based on the details below, how many hours per week are you available to mentor?
  • 2 hrs/day x 4 days
  • 4 hrs/day x 2 days
  • 4 hrs/day x 4 days
* Hours per Week 

For University Mentors - Can you attend the full 9-week course Mon-Thurs 8AM-12PM from June 9 - August 11 without missing more than three days?

For Peer Mentors - Can you attend the full 9-week course in your chosen time slot above without missing more than 3 days?
* Availability 

How many miles are you willing to travel?
Note: We will compensate for mileage over 15 miles.
* Mileage 

Campus Preferences
* 1st 
* 2nd 
* 3rd 

Computer Programming Experience
Which of the following languages/tools do you have experience with?  

* CSS 
* JavaScript 

How many years of experience in computer programming do you have?  
* Experience 

Additional Information
Why do you want to be a mentor? (in 200 words or less)  
What strengths do you bring to this internship? (in 200 words or less)  

How Did You Hear about Us?
* Indicate 

Privacy Policy
We keep your personal information private and secure.

Contact Us: Code to Success •• 111 East Broadway, Suite 900, Salt Lake City, UT 84111 •• (801) 257-3482 •• codetosuccess@sieutah.org

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