College Student 6to16 mentor interest form Survey

College Student 6to16 mentor interest form

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6to16 Online Social Network Mentor Interest Form

Please complete the information below if you are a current college student at a four-year college or university and would like to become an online mentor to 6th-12th grade students on the road to college graduation. Data collected in this form will be used for program management and evaluation purposes.

1.	First name*

2.	Last name*

3.	Gender*

4.	Race/ethnicity
	Black
	Caucasian
	Hispanic
	Asian
	Native American
	Other, please specify

5.	Parents' Educational Background (Highest Degree Attained)*

6.	Email address*

Address*

Street Address
City
State
Zipcode

8.	Phone number*

9.	Name of Current School*
	University of Chicago
	DePaul University
	Other, please specify

10.	Year in College*

11.	Please specify the type of college you attend*

12.	Your current Grade Point Average (Cumulative)*

13.	How did you hear of 6to16? (If you are a part of a university affiliated 6to16 partnership, please specify the department.)*

14.	Your Major (if declared)

15.

Your Career Interests*
Enter at least 1 response.

Career Interests

16.	Safety is of the utmost importance. Are you willing to submit to a background check to help ensure the safety of the students involved in the program?*