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Day in the Life

Name
Last Name: First Name: Middle Initial:
Preferred Name: Age: Birthday (MMDDYYYY):
email:      
 

Local Address
Street Address: City:    
State: Zip: Phone:
 

Permanent Address
Street Address: City:    
State: Zip: Phone:
 

Please Answer the Following Questions
Have you volunteered at U.Va. before?
If 'Yes', When?
What Organization?
       
Gender:
   
school:  
year:  
Racial/Ethnic Self-Description:
(for statistical purposes only, not for matching):
 
What in your experience has led you to want to be a mentor?
     
Please list your extracurricular commitments for the 2003-2004 school year. How will you budget
your time to ensure that your mentee is a priority, especially if you are involved in several other activities?
     
If you are a female, would you be willing to be matched with a male mentee?
 

Please list two references (faculty, employer, choir director, coach, etc.):

Name:

Relationship:

Phone:

email:

Name:

Relationship:

Phone:

email:
 
Do you have a car available so you can meet with a mentee who is not within walking distance?
 
 
 
 
 
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