Student Organization Contest:
Name of Organization you represent:

Date of Application (mm/dd/yy) ID# (Last 4 digits) 

First Name   Middle Initial  

 Last Name   Prefer to be called                       

Current Address

City   State  Zip   

Current Phone (   )     All Addresses the same

Summer Address

City   State  Zip   

Summer Phone (   )     Don't know your Summer address

Fall Address

City   State  Zip   

Fall Phone (   )     Don't know your Fall address

Cell Phone (   )            Gender: Male    Female 

UTA E-mai Address

Personal E-MAIL Address

Best way to contact you:        Email        Cell Phone        Home Phone

Major/Concentration:  

Are you in the Honors College?      Expected Date of Graduation

Who Referred you to UTA-HOSTS!:

Ethnic Background (for statistical purposes only):

How many mentees are you willing to take:        two       one        more then two

Please indicate the campus organizations or activities in which you have been involved:(IF YOU ARE A FOMER CAP STUDENT, PLEASE INDICATE SO HERE)

 

 

Please note those activities you enjoy during your leisure time:

Favorite Sport:

Favorite Music:

Favorite TV Show:

Favorite Movie:

Please list at least three (3) of your favorite things to do during your leisure time not covered in the previous question.  For example, do you enjoy surfing the internet, gardening, racing, shopping, spending time with friends or family, etc.? Please do not list spending time with friends.

1. 

2. 

3. 

If you have any other preferences for your mentee, please list them here:

 

The answers to these last two questions and your phone numbers & e-mail (if provided) will be provided to your match (mentor) unless otherwise indicated on this form.

I understand that I am committing to be a mentor in the UTA-HOSTS! Peer Mentoring Program

  • My commitment is for Fall 2008 and Spring 2009.

  • I will attend a mentor training session as required by the Program.

  • I will contact the Office of Student Governance & Organizations when my contact information changes.

  • I will contact my mentee(s) once a week when UTA is in session.

  • I will contact the Office of Student Governance & Organizations if I cannot reach my mentee(s) or have other problems.

  • I will turn in check-up forms and a final evaluation when they are due to the Office of Student Governance & Organizations.

Your Signature Date

You may be entitled to know what information The University of Texas at Arlington (UT Arlington) collects concerning you. You may review and have UT Arlington correct this information according to procedures set forth in UTS 139. The law is found in sections 552.021, 552.023 and 559.004 of the Texas Government Code.