Mentor/Mentee Program Application Form | Inclusive Excellence Peer Mentoring (IEPM) Program

Mentor/Mentee Application

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All fields marked with an asterisk (*) are required.

Please don't fill out this input box.

Are you applying to be a mentor or mentee?*Select one of the above.

First Name*

Last Name*

7-digit Student ID (not SSN)*

Email Address

COD student email address*

Phone*

Street Address

City

State

Zip Code

Gender*

Male

Female

Other

Race*

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic/Latino

High School Attended

High School Graduation Year

For more information, contact:

David Swope Sr., Student Diversity and Inclusion
swoped28@cod.edu