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Online Application
Status Incoming Freshman
Transfer Student
Date of Application (mm/dd/yy)
ID# (Last 4 digits)
First Name
Middle Initial
Last Name
Prefer to be called
Home Address
City
State
Zip
Home Phone
Fall Address is the Same
Fall Address
City
State
Zip
Fall Address Unknown
Cell Phone
Gender Male
Female
E-mail Address
Best way to
contact you 		Email
Cell Phone
Home Phone
IF ANY OF THE ABOVE INFORMATION CHANGES PLEASE INFORM US IMMEDIATELY
Major
Are you in the Honors College?
Undecided
CAP Student
If Undecided what major are you considering?
Ethnic Background (for statistical purposes only)
Which of the following areas are you looking to find out more about or receive assistance through the UTA-HOSTS! Program?
University Information
Student Organizations
Academic Resources
Greek Life
Reassurance/Support
Career Assistance
Campus Activities/Events
Arlington/Metroplex
Please note those activities you enjoy during your leisure time
Favorite Sports
Favorite Music
Favorite TV Shows
Favorite Movie
Please list, IN ORDER, 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, going to movies, going on the lake, etc.? Please do not list spending time with friends.
1.
2.
3.
Additional Requests/Comments
PLEASE NOTE:
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 mentee in the UTA-HOSTS! Peer Mentoring Program
  • My commitment is for Fall 2009 and Spring 2010.
  • I will contact my mentor if I have any questions or concerns, even if they haven't yet contacted me.
  • I will contact the Office of Student Governance & Organizations when my contact information changes.
  • I will contact the Office of Student Governance & Organizations if I cannot reach my mentor or have other problems.
Your Signature
Date


Updated 1/09 - 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.


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