Request a Mentor

Contact Information

Name:

Phone:

E-Mail:

Address:

Personal Information

Date of Birth:

mm/dd/yy

Year In School:

Expected Major:

Student Status:

Incoming Student

Transfer Student

International Student

Country of Origin:

Sexual Orientation:

Bisexual

Gay

Lesbian

Questioning

Queer

Other

If Other, specify:

Gender Identity:

Man

Gender Queer

Woman

Transgender

Other

If Other, specify:

Race/Ethnicity (Optional):

Tell us about yourself:

What are you looking for in a mentor?:

What do you hope to gain?:

Prior LGBT Involvement:

LGBTQ friend/family

Campus Organization

Same-gender relationship(s)

Discussion/support group

Bars

No Involvement

Other

Scheduling:

What times during the week would you be able to meet with a mentor?

How did you hear about mentoring?:

University of Wisconsin Stout | Wisconsin's Polytechnic University

LGBTQ Program Office

Campus Life

Request a Mentor