Name:

Email Address:

Year:

Concentration:
(If you have one)

Housing:

How did you hear about the program?

Would you rather have a male or female mentor?

Male
Female

How do you identify yourself (e.g., queer, gay, lesbian, bisexual, transgendered, questioning) and is it important to you to have a mentor who similarly identifies?

How much involvement are you looking for from your mentor?

Are there any specific things you would like to do with your mentor or with other mentor/student pairs?

What interested you about this program?

Anything else you'd like to add that might helps us in making a mentor match for you?