Date:

Name:

Permanent Address:

City, State, Zip:

E-mail Address:

Home Telephone #:

Work Telephone #:

Cell Phone #:

I prefer my Peer Mentor contact me initially :
By Phone By Email

Year in School:
Freshman Sophomore Junior Senior Grad

Attending UWEC:
Full-time Part-time Daytime Evening Day & Eve

First time College Student (yes/no):

Returning to college (yes/no):

If a returning student, how many years' break:

If a transfer student, how many transferred credits:

Transferring from:

Previous degrees (if any):


Intended Major/Program of Study at UWEC:

Intended Career Goal:

Personal Information (Optional):
Please provide any additional information or comments below you would like to share to assist in matching you with the best Mentor (such as marital status; ages of children, if any; current line of work; length of commute to university; any special needs or areas of concern, etc.).