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Please complete this form and click "Submit" at the bottom of the page in order to request an International Student Mentor.
First Name
Family Name
E-mail address
Gender
Male Female
Age
Religion
Ethnicity
Country of Birth
Country of Residence
School
Public Private
City/Country of grade school (to age 12)
Name/City/Country of high school (to age 18)
Number of years you have lived in the U.S.
Have you ever lived away from your parents/guardians?
Yes No
Languages - First
Second
Third
Siblings
0 1 2 3 >3
Areas of academic interest
How would you describe yourself? (E.g. shy, outgoing, etc.)
What do you like to do with your free time?
At your last school, list the types of activities you participated in and enjoyed
Title of your favorite book
Title of your favorite movie
Favorite type of music
Favorite band
What sport(s) do you play?
Male Female Do not care
Citizenship
Close to your age Older
Interests
Similar Different
Duration
Long-term mentor Short-term mentor
Please state how you would use the Mentor (mark all that apply):
As a resource person to call upon as needed As someone to assist with meeting other people As someone to assist with academic advice
Other information or concerns or requests
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Last Updated: 6/17/04
