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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-Holland 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
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