Date:         
Name:          *CCRI Student ID #:

Street Address:
City: State: Zip Code:
Intended Major:          Select One Business Administration Engineering and Technology General Studies Allied Health Dental Health Emergency/Disaster Management Nursing Rehabilitative Health Human Services Legal Studies Liberal Arts Science Technical Studies Undecided
Phone #:         
CCRI E-mail address:         
Hobbies/Interests:

Please indicate your protégé status:  New  Experienced

# of credits accumulated:    GPA:

I was referred to the Mentoring Program by:

CCRI Web Site Campus Recruiting Table Flyer/Brochure Online Announcement Friend
Advisor Faculty Member Other

Did either of your parents attend college? Yes  No
 

When are you are available to meet with a mentor?

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Please choose your campus:

Select One Lincoln (Flanagan) Campus Providence (Liston) Campus Warwick (Knight) Campus Newport Campus