Nuturing Initiative & Achievement (NIA) Mentor Program

"It Takes a Villiage to Raise a Child" - African Proverb

Online Mentee Application

Minority Student Services
Buffalo State College
Campbell Student Union, Suite 400
(716) 878-4631

Directions: Please fill out this form completely to ensure the best possible match. Thank you.
Full Name: Email Address: Date of Birth:

Local Address: Local Phone:
Permanent Address: Permanent Phone: Anticipated Major:  

Do you have access to a computer?

Yes No Gender : Male Female

Do you commute or live on campus? Commute On-Campus  


Please list the clubs and organizations you are interested in joining:


Do you have any children?


Yes No  
Do you work? Yes No
Can you speak more than one language? Yes Yes If yes, what language (s) do you speak?
If yes, how many hours/wk.? 10-15 15-20 20+
What is your current status? Freshman Transfer    

If you are a transfer student, from what school did you transfer?

Did you receive an Associates Degree? Yes No  
What is your mentor preference? No preference Male Female
Do you prefer to mentor a student who is: Traditional Non-Traditional No preference

Please list any clubs and/or organizations you are involved in:

Please answer the following questions as thoroughly as possible. The more elaborate you are, the easier it will be to find a good match. Thank you.
What are your career goals?
What are your personal goals?
What qualities do you value in a mentor?
What would you like to get out of being mentored?
Please list your interests and hobbies:


If you have any comments, concerns or questions, please contact us at the Minority Student Services office, suite 400 of the Campbell Student Union, (716) 878-4631. If you are experiencing technical difficulties with this form or would like one mailed to you, please email us.

March 2004