Mentorship Registration Form

Personal Information

* First Name

Preferred First Name

Middle Name

Maiden Name

* Last Name

* Gender Female Male

* Ethnicity

Please check all that apply:

American Indian/Alaskan Native
Black/African American
Hispanic/Latino
Asian/Pacific Islander
White, Not of Hispanic Origin
Other (please specify)

Contact Information

* Address

* City

* State

* Zip

Home Phone

Business Phone

* Primary Email

Secondary Email

Education Information

* Cornell School/College

* Class Year

Undergrad. Degree(s)

Major

Have You Attended Graduate School? Yes No

If yes, please enter the following information:

College

Class Year

Degree(s)

Major

Career Information

Employer

Address

City

State

Zip

Occupation

Job Title

* Career Field

Program Information

Have you ever been a mentor? Yes No

Matching Preferences

Where possible match me with a student with the same (check all that apply):

Match me where I'm needed the most.
The program staff will do their best to select a student who matches the preferences indicated.

Miscellaneous

Other comments that might be relevant to your role as mentor:

Should we be unable to arrange a student/mentor match would you be interested in learning about other student advising programs at Cornell? Yes No

Information for Mentors