Protégé Application :: Get a Mentor :: Office of Mentoring Services and Leadership Development

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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
Other

Home Address :

Street
City
State	Zip

Home Telephone:

Home Email Addresss:

Campus Address

Campus or cell Phone:

Campus Email Addresss:

Emergency Contact Information
(Parent/Guardian)

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 the Vice President for Diversity, Equity and Multicultural Affairs
	Indiana University, Bloomington

Office of Mentoring Services and Leadership Development
A unit of the Office for Diversity, Equity, and Multicultural Affairs
Eigenmann Hall South Room 619
Bloomington, Indiana 47406-7511, Tell: 812.855.3540, Fax: 812. 812-856-0445
Last updated: January 21, 2011 | Comments: smithpd@indiana.edu