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Academic Support Services (4PAS & Peer Mentoring) Enrollment Form
Today鈥檚 Date:
Programs
Are you interested in:
4PAS
(note: click on the links for a description)
If you are interested in a Peer Mentor, would you prefer male or female?
No Preference
Male
Female
Do you have a peer mentor?
Choose
Yes
No
If yes, please enter your peer mentor's name:
Advisee Personal Information
First Name: *
Middle Initial:
Last Name: *
Student ID #: *
Gender:
Choose
Male
Female
Date of Birth: *
Ethnicity:
Hispanic/Latino
American Indian/Native Alaskan
Asian
Black/African-American
Native Hawaiian/Pacific Islander
White
I prefer not to answer
Other:
Student Type:
Choose
Commuter
Residential
Email address:
Personal Email: *
Cell Phone #: *
Secondary Phone #:
Current Address:
City:
State:
Zip Code:
Advisee Academic Information
I am in my:
Choose
1st
2nd
3rd
4th
5th+
year of college
Academic Status:
Choose
Freshman
Sophomore
Junior
Senior
GPA:
I am enrolled in:
Choose
University College
Summit College
Degree-Granting College
Major:
Minor:
# of completed credit hours:
Are you on current academic probation?
Choose
Yes
No
Have you ever been on academic probation?
Choose
Yes
No
Academic Advisor:
Activities and Interests
I am involved with the following student/campus/community organizations (includes clubs, fraternities, sororities, etc...):
advisee availabilty
Please indicate the best possible days and time for your advising/mentoring meetings to take place.
OMD is open Monday - Friday, 8am - 5pm
Monday
From
to
Tuesday
From
to
Wednesday
From
to
Thursday
From
to
Friday
From
to
Referral Type
Self
Faculty
Friend
Peer Mentor
Who?
Disclosure Statement
All files are held in strict confidence. By checking this box I acknowledge my completion of this form.
An asterisk (*) denotes a required field
