CONTACT INFORMATION Name (Last, First, MI) IU Southeast ID # Today’s Date IU Southeast E-Mail Address Date of Age (we correspond through IU Southeast email only) Street Address City ST Zip Preferred Phone Number Other Phone Number Gender □ □ Female Male □ □ □ □ American Indian/Native American Black/African American Multi-racial I would rather not answer Ethnicity/Race □ □ □ □ Asian/Pacific Islander Hispanic/Chicano/Latino White/Caucasian Other ACADEMICE STATUS CURRENT ENROLLMENT Must meet one of the following criteria to be considered for the Access to Success Program (Please check appropriate box) □ □ □ □ □ Freshman Junior Fulltime First Generation College Student Adult Student (age 25+) □ □ □ □ □ Sophomore Senior Part-time Twenty-First Century Scholar Minority Student
CONTACT INFORMATION Name (Last, First, MI) IU Southeast ID # Today’s Date IU Southeast E-Mail Address (we correspond through IU Southeast email only) Date of Age Street Address City ST Zip Preferred Phone Number Other Phone Number Gender □ Female □ Male Ethnicity/Race □ American Indian/Native American □ Black/African American □ Multi-racial □ I would rather not answer □ Asian/Pacific Islander □ Hispanic/Chicano/Latino □ White/Caucasian □ Other ACADEMICE STATUS CURRENT ENROLLMENT Must meet one of the following criteria to be considered for the Access to Success Program (Please check appropriate box) □ Freshman □ Junior □ Sophomore □ Senior □ Fulltime □ Part-time □ First Generation College Student □ Adult Student (age 25+) □ Twenty-First Century Scholar □ Minority Student
ats-mentee-application.docx