DATE:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Full Legal Name:
EMPL ID#:
Preferred Phone Number:
Preferred Email:
example@example.com
What is your major?
If No, what majors are you considering?
What is your career goal?
If No, what career(s) are you considering?
What courses are you enrolled in this semester?
Which subjects do you enjoy studying?
Which subject areas have been challenging for you in school?
Have you ever used academic tutoring?
Yes
No
Where you born the United States ?
What language(s) do you speak at home?
Are you a first generation college student?
What would you like your mentor to know about you? For example, your values, personal qualities and beliefs, achievements, and/or special skills.
What are hobbies and interests?
What do you foresee might impede or challenge your academic progress and success? (e.g.: job, family needs, housing, child care, etc.)?
What services/resources and/or benefits you think you might want to use this year.
Campus Events
Internships
Information About Scholarships
Social Networking
Resume & Cover Letter Assistance
Career Exploration Info & Workshops
Tutoring & Study Skills
Leaders/Professionals
Other
Availability: What days and approximate times of the week are you available to meet your Mentor for your monthly checkin? Please note times.
Rows
MON
TUES
WEDS
THURS
FRI
MORNING
1
2
3
4
5
AFTERNOON
6
7
8
9
10
EVENING
11
12
13
14
15
There are many ways to check in weekly with your Mentor. Which of the following would work best for you? (Check all that apply):
Phone Call
Text
Video Chat
Email
Other
Student's Signature:I understand that by becoming a CREAR Futures 2.0 Mentee I agree to meet monthly with my Mentor and to maintain weekly contact with him/her during the semester. I also agree to participate in at least 3 CREAR Futures 2.0 activities/events.
Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: