First Name:  Last Name:  UCI Student ID#:

E-mail (must be valid): 

Gender: Age:

Do you prefer to be paired with someone of the same gender? Yes, no, or either:

Home Country: Home University:

UCI Major:  UCI Minor/Second Major: 

What languages can you speak (other than English)?

Would you like to be assigned a student who can speak the same language(s)?

List three adjectives that best describe you:

List three things you would like to do with your mentor:

What are your hobbies and/or interests?

How often would you like to meet with your mentor? 1-2 times per week: Once every other week: 1-2 times a month:

What do you hope to gain from this program?

Is there anything else that you think would be helpful for us to know in matching you with a UCI student?