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Online Application
Name of Organization you Represent:
Date of Application (mm/dd/yy)
Last 4 Digits of ID #
First Name
Middle Initial
Last Name
Prefer to be Called
Current Address
City
State
Zip
Current Phone
All Addresses are the Same
Summer Address
City
State
Zip
Summer Phone
Summer Address Unknown
Fall Address
City
State
Zip
Fall Phone
Fall Address Unknown
Cell Phone
Gender Male
Female
UTA E-mail Address
Personal E-mail Address
Best way to
contact you 		E-mail
Cell Phone
Home Phone
Facebook
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 be matched with? One
Two
More than Two
Please indicate the campus organizations or activities in which you have been involved (IF YOU ARE A FORMER CAP STUDENT, PLEASE INDICATE SO HERE)
Please note those activities you enjoy during your leisure time
Favorite Sports
Favorite Music
Favorite TV Shows
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, 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
PLEASE NOTE:
The answers to the previous two questions, your phone numbers, and your e-mail address
(if provided) will be provided to your match (mentee) 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 2009 and Spring 2010.
  • 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


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.

Student Organization Contest
Name of Organization you Represent
Mentor Qualifications
  • GPA of at least 2.0
  • Attended UTA for 2 semesters
  • Attend mentor training
  • Be committed!



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