For Student Applicant Student Name Email Phone Major/Intended Major Minor/Intended Minor Year 2nd year 3rd year 4th year Ethnicity African American Asian Latino Native American other Mentor Preference Male mentor Female mentor No preference Mentor Department/Program Preference Yes No Mentor Department/Program Preference If you prefer your mentor be in a specific department, please indicate. For Mentor Applicant Mentor Name Mentor Phone Mentor Email Department/Program Student Preference Male student Female student No preference Student Major/Career Interest For All Applicants If you have participated in the program before, in which year(s)? If you want to keep the same mentor or mentee, please write his/her name My main academic interests Briefly describe why you are interested in serving as a mentor
