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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? Do you have a peer mentor? If yes, please enter your peer mentor's name:

Advisee Personal Information First Name: * Middle Initial: Last Name: * Student ID #: * Gender: 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: Email address: Personal Email: * Cell Phone #: * Secondary Phone #: Current Address: City: State: Zip Code:

Advisee Academic Information I am in my: year of college Academic Status: GPA: I am enrolled in: Major: Minor: # of completed credit hours: Are you on current academic probation? Have you ever been on academic probation? 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