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MOCI | Interest & Connect Form
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First Name
*
Your answer
Last name
*
Your answer
email
*
Your answer
Preferred method of communication
Option 1
Clear selection
Closet HACC Campus you are near
*
Harrisburg
Lebanon
York
Lancaster
Gettysburg
Race/Ethnicity
*
Black/African American
Hispanic/Latino
American Indian/ Alaska Native
Native Hawaiian / Pacific Islander
Asian
White (non-hispanic)
Two or More of the Above
Other:
Your Goals for Fall 2022!
Availability to Meet In-person/ Virtually in Fall 2022
*
12pm to 1pm
5pm to 6pm
6pm to 7pm
7pm to 8pm
8pm to 9pm
Monday
Tuesday
Wednesday
Thursday
Friday
12pm to 1pm
5pm to 6pm
6pm to 7pm
7pm to 8pm
8pm to 9pm
Monday
Tuesday
Wednesday
Thursday
Friday
What are some of the things you are looking for in terms of engagement and support (Check all that apply
*
Mentorship (Peer -to-Peer)
Mentorship (Student to Faculty/Staff)
Community/Civic Engagement
Career Readiness
Barbershop Talks
Food & Fellowship
Internship Assistance
Professional Development Opportunities (e.g. conferences, seminars, etc)
Personal Enrichment Opportunities (e.g. programs that provide support, guidance, and directions and include films and other interactive programming
Other:
Required
Any other additional comments or things you would like to share?
Your answer
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