First Name:  Last Name:  UCI Student ID#:

UCI E-mail (must be valid): 

Local Phone:  Cell Phone: 

Gender: Age:

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

UCI Major:  UCI Minor/Second Major: 

UCI class standing as of this fall:

Graduation date:

Have you gone abroad on EAP or IOP? (check one) Yes: No, but I will be going abroad in the future:

I have participated/will be participating in the following SAC program(s) (use as many as needed):

EAP or IOP:  Country: Program/Term: 
EAP or IOP:  Country: Program/Term: 
EAP or IOP:  Country: Program/Term: 

Would you like to be assigned a student from the country you have returned from or will be going to? Yes: No I'm Flexible:

Which country(ies):

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 mentee:

What are your hobbies and/or interests?

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

What do you hope to gain from this program?

Would you be interested in mentoring more than one international student?

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