Prescreen mentors

MENTORING PROGRAM APPLICATION
Section I: Personal Data
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Second Email
Sectional II: Academic Information
Earned Credits
Current Semester Hours
Cumulative GPA
Intended Major
Other University/College attended. Please include date range of attendance
Monday Availability

:HourMinutesAM/PM Option
until
until :HourMinutesAM/PM Option
Tuesday Availability

:HourMinutesAM/PM Option
until
until :HourMinutesAM/PM Option
Wednesday Availability

:HourMinutesAM/PM Option
until
until :HourMinutesAM/PM Option
Thursday Availability

:HourMinutesAM/PM Option
until
until :HourMinutesAM/PM Option
Friday Availability

:HourMinutesAM/PM Option
until
until :HourMinutesAM/PM Option
Check all that apply: I am interested in employment during the

SummerFallSpring

Keep in mind that you have many responsibilities as a college student. Based on a scale of 1-10, what level of commitment will you be able to offer to this position?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

Please explain.
What do you feel you can uniquely contribute to a program designed to support and encourage first year college students through their personal, social and academic challenges?
What adjustment issues do you believe first year students face as they become a part of the BC campus and how can you help them be successful?
List programs or departments you are familiar with at Brazosport College and their functions.
Please check all qualities that you feel best describe you.

PunctualTimid/ShyHonestDependableProcrastinatorStudent-centeredSarcasticMotivatedNonchalantOptimisticOut-goingAttentiveThoroughPerceptiveIntensePreciseImaginativeCommunicativeEfficientCarefulFastMethodicalEasygoingIndustriousEnergeticAssertiveDiligentAccurateIntuitiveIntelligentCandidCuriousDedicatedKnowledgeableCredibleInsightfulDeterminedOpen-mindedDecisiveSensitiveTenaciousLogicalRealisticSupportiveResponsibleSpontaneousFriendlyPersistentCan Produce ResultsHumorousTactfulTrustworthyWarmIntellectualThoughtfulOrganizedGregariousAnalyticalRisk-takerFlexibleSincerePersuasive
Please write the three (3) qualities that best describe the kind of worker you are.
Section III. Application Screening Questionnaire
Languages spoken other than English (not required for employment consideration)
Written

BeginningIntermediateFluent
Oral

BeginningIntermediateFluent
Section IV: Employment History
Place of employment
Position
Dates of employment
Supervisor
May we contact
Phone Number

Area CodePhone Number
Job description/responsibilities
Section V: References
Please include three references: name, title email, and phone number (do not include relatives).
Reference 1
Reference 2
Reference 3
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Initials
Date

MonthDayYear
Unofficial Transcript

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Resume

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Copy of class schedule

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MENTORING PROGRAM APPLICATION