Student Support Services Application Form

We deliver industry-focused education that is flexible, accessible, and affordable for our diverse community.

What service(s) are you seeking?

Are you a new or continuing student of support services?Please select "New" if you have not yet completed an online application form for support services.

Student Information

First Name *This question is required.

Last Name *This question is required.

Student ID Number

Please specify your program of study.

Graduation Year This question requires a valid number format.

Street Address

Apt/Suite

City

State

Zip

County

Gateway Email Address *This question is required. This question requires a valid email address.

Phone Number

Mobile Phone

Date of Birth This question requires a valid date format of MM/DD/YYYY.

Secondary Language

Are you a first generation college student?

Are you a single parent?

Do you have a documented disability?

Are you in need of tutoring?

Interests or Hobbies (Check all the apply):

Please specify which language you are bilingual in:

What are you hoping to gain from a mentoring relationship?

What are you hoping to gain from support services?

Why did you choose to come to Gateway? What are your goals?

What do you feel your strengths are?

If you answered yes, please list them:

Are you available to meet with your assigned mentee(s) at a minimum 3 times per semester and have contact via (in-person, text, email or phone) at least twice a month?

Can you commit to participate for a minimum of one year from the time you are matched with a mentor?

Please explain any particular scheduling issues.

Consent To Release Information:
By entering my name, I allow support staff to verify my eligibility and track my progress through information obtained from staff, faculty and/or administration at Gateway Technical College. The above information is true and complete to the best of my knowledge. I understand that this information will be treated as confidential.

*This question is required.

Clear

Signature of

Acknowledgement of Consent:

*This question is required.

By checking this box I acknowledge I read and understand the Consent to Release Information.

Thank you for your interest in our mentoring program! Space is limited and students will be notified of their selection to participate.

Mentor Facilitator will pair committed mentors and mentees for the entire academic year and will provide Intrusive Case Management for the first semester to both the Mentor/Mentee.

Mentor Facilitator:

Mark Hargrove

P: 262.564.2736 | E: hargrovemv@gtc.edu

Questions? Please feel free to reach out to your Multicultural/Veteran Student Support Specialist:

Multicultural Support Specialist:

Jomarie Coloriano, Racine

P: 262.619.6440 | E: colorianoj@gtc.edu(link sends e-mail)

Desmar McDuffie, Kenosha

P: 262-564-2546 | E: mcduffied@gtc.edu(link sends e-mail)

Mary Xiong, Elkhorn – Burlington

P: 262-741-8032 | E: xiongm@gtc.edu(link sends e-mail)

Veteran Support Specialist:

Edwardo Vargas, Racine
P: (262) 619-6492 | E: vargase@gtc.edu

Robert Swanson, Kenosha
P: (262) 564-2366 | E: swansonr@gtc.edu

Thank you for your interest in our services!

Mentor Facilitator:

Mark Hargrove

P: 262.564.2736 | E: hargrovemv@gtc.edu

Questions? Please feel free to reach out to your Multicultural/Veteran Student Support Specialist:

Multicultural Support Specialist:

Jomarie Coloriano, Racine

P: 262.619.6440 | E: colorianoj@gtc.edu(link sends e-mail)

Desmar McDuffie, Kenosha

P: 262-564-2546 | E: mcduffied@gtc.edu(link sends e-mail)

Mary Xiong, Elkhorn – Burlington

P: 262-741-8032 | E: xiongm@gtc.edu(link sends e-mail)

Veteran Support Specialist:

Edwardo Vargas, Racine
P: (262) 619-6492 | E: vargase@gtc.edu

Robert Swanson, Kenosha
P: (262) 564-2366 | E: swansonr@gtc.edu

Student Support Services Application Form

Learning Success - Support Services