Male Mentoring Program Application
Date *
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Semester *
Last Name *
Your answer
First & Middle Name *
(If you do not have a middle name, only type in first name)
Your answer
Last for digits of your social security number *
Your answer
HCC ID number *
Your answer
Birth Date *
MM
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DD
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YYYY
Age *
Your answer
Check the ethnic group with which you most identify:
Mailing Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Home Phone *
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Can we send you text messages?
Personal E-Mail *
Your answer
MySpace URL
Your answer
Facebook URL
Your answer
Are you a U.S. Citizen? *
If no, permanent resident you a U.S. Citizen?
If no, please provide registration number
Your answer
Do you have a physical or mental impairment which substantially limits one or more major life activities such as: seeing, hearing, speaking, walking, learning, or working?
Your answer
Educational Goals/Challenges:
Who is your Faculty Advisor?
Your answer
What careers are you interested in?
Your answer
What weaknesses or life challenges do you have that will hinder you from accomplishing your goals?
Your answer
OPTIONAL: Have you ever been charged and/or convicted of a crime?
Your answer
Check any degrees / certificates that you are enrolled in or currently have
If GED, what semester do you anticipate becoming a full-time student?
Anticipated Graduation/Completion Date
MM
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DD
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YYYY
Anticipated Graduation/Completion Major(s)
Your answer
Anticipated Graduation/Completion Minor
Your answer
Are you planning to transfer to a 4 year college or university? *
If yes, please list intended transfer institution(s):
Your answer
Are you enrolled as a full-time student at HCC? *
Do you plan to complete your Associate Degree or Certificate at HCC? *
Level of English you are placed in and/or enrolled for (if any)? *
Required
Level of Math you are placed in and/or enrolled for (if any)? *
Required
Financial/Eligibility Information
Are you a first-generation college student (neither parent/guardian has a 4-year college degree)?? *
Were you awarded Financial Aid? *
If yes, are you work-study eligible?
Check the box below that has your family’s income
Household Family Income
Test
Monday
Tuesday
Wednesday
Thursday
Friday
8 - 9 am
9-10am
10-11am
11am-12pm
12-1pm
1-2pm
2-3pm
3-4pm
4-5pm
5-6pm
6-7pm
7-8pm
Please list any other commitments that may affect your availability for tutoring services that are offered by the program (This includes any employment or standing commitments).
Your answer
Applicant's Certification
I certify that the information contained in this application is correct and complete to the best of my knowledge. By signing
this application, I authorize FLI/ PRIDE to review my qualifications for the program, including references, employment
checks, and verification of education in order to determine my suitability for the program. I also give my consent for
FLI/PRIDE to periodically access my school records for data collection purposes as well as to check my academic
progress.
By typing your name below, you agree that this is valid as your signature *
Signature *
Your answer
Date
MM
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YYYY
Submit
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