Date: 

Name: 

Sex: Female Male              Age: 

Home Country: 

Home City/State:

Local Mailing Address:

How long have you lived in Ann Arbor? 

How long do you plan to stay? 

E-mail: 

Phone: 

Cell Phone: 

Emergency contact name:
Emergency contactPhone: 

College & program or major: 
Freshman   Sophomore   Junior   Senior   Grad Student

Means of transportation: 

Religious preference if any (optional): 

Skills/ Interests/ Hobbies: 

________________________________________________________________________

Why are you interested in the American Grandparents program?

Did you participate in American Grandparents Program in previous years?

How often would you like to meet with a mentor?

Additional Comments:

Your answers to these questions will be read by the program volunteers in order to get an idea of who you are, and will be the basis for their selection of program participants.