Mentor Registration Form
2011-2012

Please Note

Questions? Contact the Professional Development Office via our contact form or (785) 670-1184.
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Volunteer to mentor a first-year Washburn Law student by completing and submitting this form.

To complete this form:

Your Name

* Title:

* First Name:

Middle Name:

* Last Name:

Suffix:

Home Information

Street/P.O. Box:

City:

State:

Zip/Postal Code:

Phone Area Code:

Phone Number:

Email:

Employer

Business or Firm Name:

Your Title:

Street/P.O. Box:

City:

State:

Zip Code:

Phone Area Code:

Phone Number:

Phone Extension:

Email:

Educational Background

Law School:

Law School Graduation Year:

Undergraduate School:

Undergraduate Major:

Undergraduate Graduation Year:

Practice Areas / Other Information

Practice Area 1:

Practice Area 2:

Special Interests:

Non-Legal Work Experience:

Comments/ Suggestions:

Contact Preference

* Location: Home Work