Latino Cultural Center Embajadores Mentor Program
Mentee Application
Full Name: ______
Age: ______
Date of Birth: _____/______/______
Gender: ⬜Male ⬜Female
Country of origin: ______
Street Address: ______
City: ______
State: ______Zip: ______
Telephone: ______
Email: ______
Emergency Contact:
Name: ______
Phone: ______
Relationship: ______
Class Standing (check one): ⬜Freshman ⬜Sophomore
⬜Junior ⬜Senior
GPA: ______
Has anyone in your family attended college? ⬜Yes ⬜No
If yes, who (i.e.: father, mother, brother, etc.) ______
______
Would you prefer to have a mentor that speaks Spanish?
⬜Yes ⬜No
Have you already taken the SAT or ACT? ⬜Yes ⬜No
If yes, what was your score? ______
If no, when do you plan to take the test? ______
What was your score on the PSAT? ______
How would you classify your family’s socio-economic status?
Lower ⬜ Lower middle ⬜ Middle ⬜ Middle upper ⬜ Upper ⬜
Are you familiar with the financial aid process? ⬜Yes ⬜No
Careers or areas of study you are interested in: ______
Student Organizations & Other Activities you are involved in: ______
Feel free to provide interests and hobbies (sports, music, movies, religion, books) on a separate attached sheet.
Do you work? ⬜Yes ⬜No
If yes, where and how often? ______
Tell us why you want to join the Mentoring program? (Attach separate sheet if necessary) ______
What do you hope to gain from this program? (Attach separate sheet if necessary)
______
Will you be able to find your own transportation to all activities?
⬜Yes ⬜No
What do you plan to do after graduation? (Check all that apply)
⬜Military ⬜Community/Jr. College ⬜Four Year University ⬜Work ⬜Other: ______
I will be committed to the Embajadores Mentor Program for the 2012-2013 school year.
Print Name: ______
Signature: ______
Please return this application immediately to
Mida Grover or Kyle Morales. Thanks!
Schedule of Activities – Fall 2012
Are you available to participate in the following scheduled activities?
Applications are due by September 17. See end of form for instructions.
1. Latino Heritage Month Opening Ceremony @ LCC, Friday 9/14, 4-7 pm (optional) ⬜Yes ⬜No
2. Welcome Reception @ Jefferson High School, Tuesday 9/18, 6-8 pm ⬜Yes ⬜No
3. Jefferson High School College Fair, Wednesday 9/26, 5:30-7:30 pm ⬜Yes ⬜No
4. SAT/ACT Information Workshop @ Jefferson High School, Tuesday 10/9, 6-8 pm ⬜Yes ⬜No
5Día de los Muertos Preparation @ LCC, Thursday 10/18, 6-8 pm (optional) ⬜Yes ⬜No
6.Application/Admission Essay Workshop @ Jefferson H.S., Tuesday 10/23, 6-8 pm⬜Yes ⬜No
7. Día de los Muertos @ YWCA, Friday 10/26, 4-7 pm (optional)
⬜Yes ⬜No
8. Current Student Forum @ LCC, Tuesday 11/13, 6-7:30 pm
⬜Yes ⬜No
9. End of the Semester Celebration! Tuesday 11/27, 6-8 pm
⬜Yes ⬜No
Interests: (please fill in relevant areas of interest)
Music:
______
Books/Magazines:
______
TV/Movies:
______
Outdoor Activities:
______
Sports/Recreation:
______
Religion:
______
Other:
______
The Latino Cultural Center at Purdue University is an equal access/equal opportunity institution