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Get a Mentor
Protégé Application
Also available: Word file
Name :
(Last, First, Full Middle Name)
Student ID # (10 digit PeopleSoft)
Gender : Male Female
Date of Birth
Month Day Year
High School:
T-Shirt Size
Ethnicity African American Latino: Caucasian
Asian American Native American Bi-racial
Home Address :
State Zip
Home Telephone:
Home Email Addresss:
Campus Address
Campus or cell Phone:
Campus Email Addresss:
Emergency Contact Information
Are you in Groups Program? Yes No
(if yes, who is your advisor)
Are you in the 21st Century Scholars Program? Yes No
Are you in the Hudson-Halland Scholars Program? Yes No
Are you a first generation college student? Yes No
Your Anticipated Major
What are your extracurricular interests or hobbies?

What do you think your greatest challenges as a college student will be?

If you were to become involved with a student organization, what would it be and why?

What do you hope to accomplish by participating in the FASE Mentoring Program?

Academic honors/scholarships

Signature Date

Office of Academic Support & Diversity
Indiana University, Bloomington

Office of Mentoring Services and Leadership Development
Ashton-Weatherly 202, 1800 E. Tenth Street, Bloomington, Indiana 47406-7511, Tell: 812.855.3540, Fax: 812.856.5152
Last updated: 23 August, 2007 | Comments: smithpd@indiana.edu
Copyright © 2007 The Trustees of Indiana University, Copyright Complaints