Full Name          
    Phone Work/Cell          
    E-Mail Addr        
    Classification           
    Option                   

    Local Address  
                 
    
    Home Address (include phone)
                 


    Technical Courses (CS, Math, Physics etc.) list current first 
                 

    Usual Available Days and Times 
                 

    Please provide an overview of program goals:
                 

    Please provide a brief career plan/personal profile (list of work 
    experience, educational background, hobbies/special interest, etc).
                 

    I would like to gain knowledge of career paths in the following fields:
                 

As a Protege participant in the CS Mentorship program, I agree to make every effort 
to communicate with my mentor at least once per week. I also agree to make scheduled
meetings at the agreed upon times and failure to do so may result in my dismissal from 
the program. I will report issues or problems with  my Mentor/Protege relationship to 
program leaders or department representatives.

I have read the Mentoring Program announcement and understand the 
expectations and responsibilities of a Protege in the Program.

                 Yes 
                 No 

DISCLOSURE: Personal information provided on this form is given on a voluntary 
basis. Failure to provide this information will not result in ineligibility for the 
mentoring program, however it may result in an unsuccessful match.