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Enrollment Form

* Denotes required field

First Name*
Last Name*
Date* Sunday, 05/20/18
Phone Number*
Current Year Level
Gender Male Female
Address Resident Commuter
Campus or Local Address
Parent/Guardian First Name*
Parent/Guardian Last Name*
Parent/Guardian Email*
Parent Phone*
Have you used EMPOWER or Structured Monitoring before? Yes  No
If so, when was the last time you used this service?
Who did you meet with?
Would you like to continue meeting with the same mentor if possible? Yes   No
We look forward to meeting you at your initial appointment. Is there anything else you would like us to know before then? (250 character limit)
In what level would you like to enroll? Level 1: $660/semester
Level 2: $1320/semester