Date:
Name: *CCRI Student ID #:

Street Address:
City: State: Zip Code:
Intended Major: Select One Business Administration Engineering and Technology General Studies Allied Health Dental Health Emergency/Disaster Management Nursing Rehabilitative Health Human Services Legal Studies Liberal Arts Science Technical Studies Undecided
Phone #:
CCRI E-mail address:
Hobbies/Interests:

Please indicate your protégé status:  New  Experienced

Did either of your parents attend college? Yes  No
 

Days and Times you are available to meet with a mentor:

Please choose your campus:

Select One Lincoln (Flanagan) Campus Providence (Liston) Campus Warwick (Knight) Campus Newport Campus