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Mentoring Program Application
Name
Address
City
State
Zip code
Phone
Major
Enrollment status
Select one
Full-time
Part-time
Number of quarters attended
at Clark State
Select one
1 - 4
5 - 8
9 - 12
Over 12
Credit hours attempted
Credit hours completed
Accumulative GPA
Degree sought
Select one
AA
AS
AAB
AAS
ATS
Certificate
Other
Are you employed?
Select one
Yes
No
Hours worked per week
Select one
Less than 10
10 - 30
31 - 40
Over 40
What support services do you feel would be of assistance to you?
Please check all that apply.
Assertiveness skills
Career planning
Developmental classes
Counseling
Academic support
Tutoring
Handicapped services
Financial aid
Student life programs
Minority activities
Hobbies and other areas of interest:
Because you are completing this online, you will need to come in to the Campus Ministry Office to sign the application before mentoring can begin.
