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SPMPApplication09 - SPMP Mentee App Fall 09

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Transfer, Re-Entry, &
Student Parent Center University of California, Berkeley
Format B Updated on 03/23/2009
STARTING POINT MENTORSHIP PROGRAM (SPMP)
MENTEE Application
For office use only:
Semester: Fall ______ Spring ______ Mentor:
1
st
attempt:
/
/
Telephone Email
2nd attempt:
/
/
Telephone Email
3rd attempt:
/
/
Telephone Email
Circle one:
Active / Inactive
Date Received:
by:
The goal of this program is to offer California Community College students an opportunity to connect with UC Berkeley
student mentors who can provide appropriate information, access to resources, and share their campus experience. Please
complete the following information thoroughly and clearly. Signing this document also grants your mentor permission to
review the following pages.
Last Name:
First:
Middle:
Address:
City:
Zip:
Telephone: (
)
-
Email:
: Social Security Number Last 4 digits only
This information is only used to verify that students have participated in Starting Point (SPMP) when applying to UC Berkeley, it
will be not used for any other purpose. SPMP is one criterion used when considering applicants for UC Berkeley admission.
Community College:
Intended Major:
Please Indicate Your Expected Transfer Year:
Fall 2010 Fall 2011 Fall 2012 Fall 2013
Employed? Yes No
(In addition to academic course load)
Hrs per week:
For statistical purposes only:
African-American/Black American Indian Caucasian
Date of Birth:
/
/
Age:
Gender: M F
Ethnicity:
Asian/Asian-American Hispanic/Chicano/Latino Other
Have your parents received a Bachelors of Arts/Science Degree from a four-year institution in the U.S.? Yes No
Please indicate with a check mark all that apply:
Transitioning (18-24 yrs.)
Re-entry (25 yrs. and above)
Veteran
Foster / Independent Care
FOR STUDENT PARENTS ONLY:
Married Student Parent Single Student Parent Children’s ages:
Please indicate with a check mark if you are or have been a part of any of the following programs:
UCB’s Transfer Alliance Project (TAP) PUENTE MESA Other :
Would this be your first time participating in the Starting Point Mentorship Program? Yes No
Preferred method of contact with UC Berkeley mentor [choose two (2)]:
No Preference Telephone Email Online Chat At UC Berkeley Campus At Your Community College
Transfer, Re-Entry, &
Student Parent Center University of California, Berkeley
Format B Updated on 03/23/2009
Mentee Agreement
Both parties (mentee and mentor) are required to follow the program guidelines to ensure the integrity and
success of the Starting Point Mentorship Program.
1. I agree to inform my mentor and provide him/her with a way to contact me.
2. I agree that any information shared by the mentor is considered confidential unless stated otherwise.
3. I agree not to share the mentor’s private contact information without permission.
4. I agree not to enter into a romantic relationship with the mentor while participating in the Starting Point
Mentorship Program.
5. I agree that my information may be shared with representatives at TRSP..
6. I agree that either the mentor, TRSP staff or I may terminate the mentee/mentor relationship at any time.
7. I understand that at any time during my participation in the program I can contact Omar A. Ramírez z by
e-mail oramirez@berkeley.edu or by phone at (510) 643-9896 with any concerns or issues.
8. I understand that in order to participate in Starting Point I am expected to:
Remain engaged and connected throughout the program with my mentor: in person, via
telephone, and/or via e-mail
Respond to my mentor’s e-mails or phone message
Arrange a method to connect with my mentor in person, via telephone, and/or via e-mail
Notify my mentor in advance if I am able to attend a pre-arrange meeting
9. I understand the I can expect the following from my mentor:
Advice on study strategies such as time management, setting realistic goals, utilizing resources
and services, and taking advantage of enrichment opportunities
Information on mentor’s academic and social experiences at UC Berkeley
Discussions on the differences between community college and Cal
Encouragement to explore academic potential and achieve goals
Support and motivation to continue in higher education
Perspective of the academic rigors at UC Berkeley
10. I understand that SPMP mentors ARE NOT academic advisors and as such will not prepare an
academic plan or advise me on course requirements. I will seek academic advise from a
community college counselor or transfer counselor.
11. I understand that all mentors participating in the Stating Point Mentorship Program will be required to sign
a similar agreement.
12. I agree that at any time I need to remove myself from the program, I will inform my mentor and/or TRSP
representatives as soon as possible.
Name:
Today’s Date:
/
/
Signature:
If submitting application electronically, please check box.
PLEASE KEEP A PHOTOCOPY FOR YOUR RECORDS!
Please complete forms and email or send to:
OMAR A. RAMÍREZ (oramirez@berkeley.edu)
Coordinator of Academic Preparation Programs and Services
Transfer Re-entry & Student Parent Center
104 César Chávez Student Center
University of California, Berkeley
Berkeley, CA 94720-4260
Transfer, Re-Entry, &
Student Parent Center University of California, Berkeley
Format B Updated on 03/23/2009
STARTING POINT MENTORSHIP PROGRAM
PRE-SURVEY – 2009
Thank you for your assistance. Your responses will help us best design the mentorship program to meet your
needs as well as those of future participants. Your identity will be kept anonymous. Please submit these surveys to
the Program Coordinator, Omar A. Ramírez at 104 Cesar Chavez in person or via e-mail oramirez@berkeley.edu
Please indicate your:
1. Current Semester: Fall
Spring
2. Age
3. Gender: Male Female
4. Ethnic background (For statistical purposes only. This question is optional.)
African-American/Black American Indian White/Caucasian
Asian/Asian-American Hispanic/Chicano/Latino Missing :
5. What community college do you attend?
6. When do you plan to transfer?
7. What is your intended major?
8. Have you ever been to the Berkeley campus prior to this mentorship?
* If yes, please indicate the reasons why you came to the campus?
Class visit/Campus tour
Sporting Event(s)
Cultural Event(s)
Summer Academic Program(s)
Cal Day
Other (Please Indicate)
For the following questions, please select the answer that best you will be selecting between:
1=Not Familiar, 2=Somewhat Familiar, 3=Familiar, 4=Very Familiar
9. How familiar are you with the following:
a. The experience of being a transfer student at Berkeley after transferring
b. Classes at Berkeley
c. Departments at Berkeley related to your academic interests
d. Berkeley faculty members
e. Major-related clubs at Berkeley
f. Career-related clubs at Berkeley
g. Other extra-curricular activities for students (e.g. campus gym, culture-related clubs,
theatre/arts groups
10. How familiar are you with the following areas of UC Berkeley:
a. Libraries
b. Financial aid office
c. Career Center
d. Student Learning Center
e. Transfer, Re-entry, & Student Parent Center
f. SLAS/EOP
g. Disabled Students Program
Transfer, Re-Entry, &
Student Parent Center University of California, Berkeley
Format B Updated on 03/23/2009
11. How many hours per week would you like to meet / have contact with your mentor?
12. How do you hope to benefit from having a mentor?
13. We want to make mentors available to as many students as are interested. Do you know of any
reasons why other community college students would not sign up for this mentorship program?
14. Any other comments? (Please use additional space if necessary)
Thank you!
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