3MP Program Student Application
Today’s Date: _________
Student ID #_______________ DOB: __________
Name: __________________________________ Address: _______________________
City: __________________ State: _____ Zip: ________ Ethnicity: _________
Phone(c): _________________ Phone (h): ________________ Email: ________________________
Languages Spoken: ________Academic Program_______________ (Circle) Transfer/Diploma Track
Semesters at Cape Fear Community College? ____Cumulative GPA____GPA last semester? ____
Emergency contact: Name/Relationship: _________________________ Phone: _______________
Do you get assistance with homework? If yes, by whom? _________________ Receive Pell Grant: Y/N
In which classes do you feel you need help? _______________________________________________
Do you seek to further your education beyond community college? Yes or No.
If yes, please explain: _______________________________________________________________
As a willing participant in the Mentor Program, I commit to working with my mentor through the
duration of the program, attending all scheduled 3MP meetings, communicating with my mentor and
allowing 3MP staff to access my school records (schedule, grades, etc.). Emergencies happen to all of
us. Should I be unable to keep a meeting, I shall call in advance to reschedule. I agree to develop
personal goals with my mentor and to be open to coaching and feedback from my mentor. In the event
that I wish to discontinue my match for any reason, I will first notify 3MP staff & discuss this. I also
give permission for 3MP to use my photograph or likeness for advertising and recruiting purposes in
perpetuity. I will make no monetary or other claim against Cape Fear Community College, or staff for
such use of these photographs.
_____________________________________
Student Signature
____________________________
Date
_____________________________________ ______________________________
Parent’s Signature (If under 18)
Date