Multicultural Center for Academic Excellence

ACADEMIC SUPPORT & SERVICES

Please use this form to sign up as a faculty participant for the Mentor Program.

First Name:

Last Name:

Academic Title:

E-mail:

Campus Address:

City:

Department:

Phone Number:

Please respond to the questions below :

Yes, I wish to participate for the program this year

Yes, I wish to participate but not this year. Please check with me later.

No, I do not wish to participate

Are you willing to mentor a student interested in your field but currently admitted to another college or undecided on their major?

Yes No

List your Academic Interest:

List your Research Interest:

Hobbies/Outside Interest:

Please provide information on your experience mentoring students ?

Have you participated in the President's Distinguished Faculty Mentor Program as a mentor in the past?:

Any other information you would like to include in your profile: