Last name:
First name:
Email:

Local Address:


Home Phone:
Work Phone:

Age: Year in School: Not Applicable Freshman Sophomore Junior Senior Graduate

Gender : Male Female

Current occupation or field of study:

Work/life experiences:


I can:
Drive my car to meet my partner
Bicycle
Take the bus
My partner must come to me


When are you free to meet with a partner:

Flexible:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Mornings:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Afternoons:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Evenings:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

How did you hear about the Conversation Partners Program?


Have you been a Conversation Partner before?
Yes No

Other Comments: