宅男研究所

iSTEM Mentoring Application

Name Name First Last
E#
Birthday Birthday / MM / DD YYYY
Local Address Local Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Phone Cell Phone - ### - ### ####
Permanent Address (If different from Local Address) Permanent Address (If different from Local Address)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Email
Current Semester GPA
Current Cumulative GPA
Major
If other, please specify.
Minor
Major GPA (You can calculate this by averaging grades in your major classes)
Year in School
Expected Graduation Date Expected Graduation Date / MM / DD YYYY
Name of Faculty Member Reference (STEM faculty member preferred)
Email Address of Reference
List your extra-curricular activities and/or organization memberships. (If none, put NONE)
What do you like to do for fun on campus
Are you willing to participate in online training for the Panther Peer Mentoring program?

Are you willing to participate in online training for the Panther Peer Mentoring program? YES NO
Will you be committed to meeting (email, text, FaceTime, etc) with your mentee AT LEAST once per week?

Will you be committed to meeting (email, text, FaceTime, etc) with your mentee AT LEAST once per week? YES NO
T-Shirt Size

T-Shirt Size Small Medium Large XLarge 2XLarge 3XLarge
Using a word document, please write a brief (one paragraph) summary stating why you want to be an iSTEM peer mentor and what advice you would give your younger iSTEM mentee.

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