M2 Success Initiative Mentoring Questionnaire

Mentoring Questionnaire

Please answer the following questions fully and honestly in order for you to be correctly matched with a mentor.

M2 Mentoring Student Questionnaire

Full Name

Email Address

Phone Number

Day Phone Number

Address

City

State

Zip

Ethnicity

Language Spoken

Date of Birth

Age

Emergency Contact

Emergency Contact Phone

Relationship

Student ID Number

Cumulative GPA

GPA Last Semester

Number of Children

Marital Status

General Information

How long have you been enrolled at LCC?

Do you feel you need help in any classes?

Do you get assistance with your homework? If yes, by whom?

Name a teacher whose class you've attended and who knows you well.

In what extracurricular activities do you participate?

Have you thought about your education beyond community college? If yes, please explain.

Do you currently work? If yes, give employer's name, phone number and your number of hours worked weekly.

In which activities do you participate during your free time? (music, reading, sports, etc.)In which activities do you participate during your free time? (music, reading, sports, etc.)

What do other people tell you that you are good at?

What do you think you are good at?

What do you like most about yourself?

Who do you look up to or admire?

Tell us about yourself

Agree or Disagree

As a willing participant in the Mentor Program, I commit to working with my mentor through the duration of the program, attending all scheduled meetings with my mentor, and communicating weekly with my mentor. Emergencies happen to all of us. Should I be unable to keep a meeting with my mentor, I shall call in advance to reschedule. I agree to develop personal goals with my mentor and to be open to coaching and feedback from my mentor. In the event that I wish to discontinue my match for any reason, I will first notify the (Mentoring Coordinator/Program Director, etc), and discuss this before discontinuing.

I agree with the above statement.

Please leave this field empty.

For more information:
Jamal McMillion
Minority Male Success Initiative Coordinator
Administration (Building 003), Room 140G
Phone: (252) 527-6223, ext. 343
Fax: (252) 233-6867
Email: jlmcmillion66@lenoircc.edu

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