EmailMe Form - NSLC CO/XO Mentor Intake Form

Contact Information

Name *

First Last

Email *

Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Your address is required in order to receive course materials prior to the class.

Phone *

Best way to contact you? *

Email

Phone call

Text message

Hold CTRL to choose all that apply. If choosing text message, ensure the phone number listed is your mobile phone.

Best time to contact you?

Call/Text between 8AM - 12PM

Call/Text between 12PM - 4PM

Call/Text between 4PM - 8PM

Call/Text me anytime

Please answer this question if you selected phone call or text message. Hold CTRL to choose all that apply.

General Information

Who referred you? *

Have you attended CSLC? *

Yes

No

If you have attended CLSC, when did you attend?

MM / YYYY

Have you ever served as a CSLC Mentor? *

Yes

No

If so, how many times?

Include month and year of most recent experience.

MM / YYYY

I feel comfortable mentoring to different Navy warfare communities and to all members of the CST (PCO, XO, CMC & COB spouses). *

Yes

No

I understand that some mentoring sessions may include members of the TRIAD (PCO, PXO, CMC & COB). *

Yes

No

Biography *

You can upload your biography or enter text in the box below.

Headshot

While it's not mandatory to provide a headshot, you have the option to upload one for use during your class.

Spouse Information

Name of Spouse *

Spouse's Rank *

Navy community (surface, aviation, submarine, etc.). *

Spouse's current position *

Spouse's PRD *

MM / YYYY

Please list locations and dates of current and prior commands. *

	Location	Dates	XO or CO?
Current
Prior
Prior
Prior

Unique Experiences

Overseas Experiences

Geo-bachelor Experiences

(Your own spouse, other TRIAD members)

Family Challenges

(Ailing family members, EFMP, new babies, left child(ren) in a different location, college students, etc.)

Command Support Team (CST) Challenges

(Incomplete CST experiences, other CST challenges)

Crisis Experiences

(Natural disaster, mishap, major injury, serious illness of command member or their family, loss of command member or their family, etc.)

FRG and/or Spouse Group Experiences

Ombudsman Experiences

Past Mentoring Experiences

(COMPASS, CORE, professional, community, etc.)

Past Involvement in Spouse Education

(Planning, organizing, presenting)

Please share why you would like to mentor

Additional Comments

(Anything else you would like us to know)

Thank you!

Thank you for taking the time to fill out the Mentor Intake Form. As mentoring opportunities become available, the Mentor Liaison or Steering Committee Director will be in contact with you.