*  required fields

* Name:   

Mailing Address:    

* Street:  

* City:   

* State: *  Zip:

* Home phone:  

* Cell phone:

* E-mail:  

Major:

Date of Birth

Race/Ethnicity:

Please check all that apply:
FRESHMAN TRANSFER   FEMALE MALE

My Hobbies include:

Is there any specific information about yourself that would help us
in matching you with a mentor?

Please rank your preferences for mentor pairing:

Male     Female   Same Hometown    

  Same Major    Same Hobbies  Same Interests  

Anyone

Are there specific characteristics in a mentor that you would want us to consider?

What do you want to receive from your mentor?  Check all that apply:

Tutoring/Academic Support     Time Management     

Campus Resource                  Social Support     

Other (Special Skill)  

My expectation of the mentee experience is:

My expectation of the mentor is:

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     Date

THE CENTER FOR BLACK CULTURE
192 S. COLLEGE AVE.
NEWARK, DE 19716
ATTN: EACH ONE REACH ONE PROGRAM MANAGER

Deadline to return this form is Friday, August 7th
Any questions or concerns about the program should be addressed
to the Graduate Assistant at the Center for Black Culture at (302) 831-2991.