<h2>STAT Buddy Program - Freshman/Sophomore Student Participation Survey</h2>
<table>
<tbody>
<tr>
<td height="245" valign="top" width="505">
<table border="0" width="460" cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td>
<p class="textbody">Freshman and sophomore-level STAT members are partnered with junior,senior or graduate-level STAT members through the STAT Buddy Program. To participate in the program, fill out and submit this form:</p>
<form name="mail" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post">
<p><input name="recipient" type="hidden" value="kabenne@siue.edu" /><input name="required" type="hidden" /><input name="redirect" type="hidden" value="http://www.siue.edu/alumni/stat/thankyou.shtml" /></p>
<table border="0" width="455">
<tbody>
<tr>
<td class="head2a" colspan="2">
<h3 align="center">Printable Participation Survey</h3>
</td>
</tr>
<tr>
<td class="textbodybold" colspan="2"><strong>1. Your Information</strong></td>
</tr>
<tr>
<td width="127" class="text1" align="right">Last Name</td>
<td width="318"><input name="Last Name" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">First Name</td>
<td><input name="First Name" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Banner ID #</td>
<td><input name="Banner ID#" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Title Select<br /></td>
<td class="text1"><input name="Title" type="radio" value="Mr." />Mr. <input name="Title" type="radio" value="Mrs." /> Mrs. <input name="Title" type="radio" value="Ms." /> Ms. <input name="Title" type="radio" value="Miss." /> Miss.</td>
</tr>
<tr>
<td class="text1" align="right">Current Grade Level<br /></td>
<td><input name="Current Grade Level" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Expected Graduation Date<br /></td>
<td><input name="Expected Graduation Date" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Major(s)</td>
<td><input name="Major(s)" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Career Interest/Goal</td>
<td><input name="Career Interest/Goal" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">E-mail</td>
<td><input name="E-mail" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Current Mailing Address</td>
<td><input name="Current Mailing Address" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">City</td>
<td><input name="City" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">State</td>
<td><input name="State" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Zip Code</td>
<td><input name="Zip Code" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Permanent Mailing Address</td>
<td><input name="Permanent Mailing Address" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">City</td>
<td><input name="Permanent City" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">State</td>
<td><input name="Permanent State" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Zip Code</td>
<td><input name="Permanent Zip Code" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="text1" align="right">Phone Number</td>
<td><input name="Phone Number" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="textbody" colspan="2">Do you authorize the Alumni Association to release your address and phone number to your buddy so that he or she can contact you?<br /></td>
</tr>
<tr>
<td class="text2" colspan="2" align="center"><input name="Release" type="radio" value="Yes" />Yes <input name="Release" type="radio" value="No" /> No</td>
</tr>
<tr>
<td class="text1" colspan="2">Would you prefer a female or male buddy, or do you have a preference?<br /></td>
</tr>
<tr>
<td class="textbody" colspan="2" align="center"><input name="Sex" type="radio" value="Female" />Female <input name="Sex" type="radio" value="Male" /> Male <input name="Sex" type="radio" value="No Preference" /> No Preference</td>
</tr>
<tr>
<td class="text1" align="right">Where did you attend high school?</td>
<td><input name="High School" maxlength="30" size="30" /></td>
</tr>
<tr>
<td class="textbody" colspan="2">Do you participate in any clubs, activities or sports at SIUE? If so, which ones?<br /></td>
</tr>
<tr>
<td class="textbody" colspan="2" align="center"><textarea name="Do you participate in any clubs, activities or sports at SIUE? If so, which ones?" rows="8" cols="50" id="highschool"></textarea></td>
</tr>
<tr>
<td class="textbody" colspan="2">What do you wish you accomplish by participating in the STAT Buddy Program?<br /></td>
</tr>
<tr>
<td class="textbody" colspan="2" align="center"><textarea name="What do you wish you accomplish by participating in the STAT Buddy Program?" rows="8" cols="50" id="highschool1"></textarea></td>
</tr>
<tr>
<td class="textbody" colspan="2">What are you looking for in a buddy?<br /></td>
</tr>
<tr>
<td class="textbody" colspan="2" align="center"><textarea name="What are you looking for in a buddy?" rows="8" cols="50" id="highschool2"></textarea></td>
</tr>
<tr>
<td class="textbody" colspan="2">Do you have any special interests that you would like to share with your buddy?<br /></td>
</tr>
<tr>
<td class="textbody" colspan="2" align="center"><textarea name="Do you have any special interests that you would like to share with your buddy?" rows="8" cols="50" id="highschool4"></textarea></td>
</tr>
<tr>
<td class="textbody" colspan="2">Would you like to provide any other information that would assist us in making a good match?<br /></td>
</tr>
<tr>
<td class="textbody" colspan="2" align="center"><textarea name="Would you like to provide any other information that would assist us in making a good match?" rows="8" cols="50" id="highschool3"></textarea></td>
</tr>
<tr>
<td height="50" class="text1" colspan="2"></td>
<td><input type="submit" value="Submit" /><br /></td>
</tr>
</tbody>
</table>
</form>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>