STEM Protégé Form

Contact Information
Name

First NameLast Name
Campus Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Email
Ethnicity
Gender
Major
Classification
Mentor Preferences
Please indicate your preferences regarding potential mentors.
Gender
Career Interest
Ethnicity

Other
Additional Questions
Briefly explain why you are interested in participating in a mentoring program
Briefly describe your ideal mentor
Briefly describe your interests
Introduce yourself to a future mentor. Share your past experiences, college goals, future plans and/or expectations of a mentor/protégé relationship.
Should be Empty:

Contact Information