MC First Program - Student Information Form

Name: *This question is required.

Date of Birth: *This question is required.

MC#: *This question is required.

Preferred Name (How would you like to be addressed?): *This question is required.

Phone Number: *This question is required.

College E-mail: *This question is required. This question requires a valid email address.

Personal E-mail: *This question is required. This question requires a valid email address.

Preferred method of contact: *This question is required.

Academic program or interest: *This question is required.

Reason for participating: *This question is required. Please tell us what interests you about the MC First Mentoring Program

All information above will be kept strictly confidential.

If you have any questions about the program, please contact Dr. Caroline F. Toscano, ELITE, at Caroline.Toscano@montgomerycollege.edu or 240-567-2002

To participate in this program, you agree to the following:

   1.   All face to face mentoring will take place on the Montgomery College campuses.
   2.   You can stop participating at any time.
   3.   If you mention to the mentor any thoughts about harming yourself or others, your mentor has a duty to report this to the Office of Public Safety and Emergency Management.
   4.   At the end of the semester, you will fill out a brief feedback form to let us know your thoughts about your mentoring experience.

Signature of Consent
I give my consent to participate in this mentoring program. I agree to all of the above statements. I know that I can stop participating at any time. *This question is required.

Date: *This question is required.