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.