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EXCEL Program: Mentee Registration Form

Basic Information  
   
Name:
PeopleSoft ID:
Department:
Major:
First-Year Status: Freshman
Transfer
Email:
   
Local/University Address  
   
Address:
City:
State:
Zip:
Phone:
Email:
   
Permanent Address (if different than above)
   
Address:
City:
State:
Zip:
Phone:
   
Program Information  
   
I would like to receive mentoring from: Faculty/Staff Mentor
Student Mentor
Either
I am interested in these additional opportunities (check all that apply): College Success Networking Program
Transfers-in-Transition Networking Program
   
Optional Information  
   
Gender: Male
Female
Ethnicity: African-American
American Indian
Anglo-Saxon
Asian/Pacific Islander
Hispanic
Other
   

 

For more information, contact the Dean of Students Office at 713-743-5470.

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