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Brockport/ SYE / Peer Mentor Application Form

Peer Mentor Application Form

Part One: General Information

Name: Banner ID:

Campus/Local Address: E-mail:

Home Address:

Cell Phone: Home Phone:

Major(s):  Minor(s):

Class year in fall 2012:  Cumulative GPA:

Part Two: Campus Activities and Involvement

Please list any clubs, organizations, jobs or activities you have been involved with outside of the classroom as a Brockport student. Please also indicate the approximate time commitment and whether or not you intend to continue with the activity during the Fall 2012 semester. If you anticipate involvement in a new activity during the Fall 2012 semester, please note the activity below.


Hours per Week
Fall 2012

Part Three: Essay Questions

Please respond to the following questions. Please limit each response to a maximum of 300 words.

  1. Why are you interested in becoming involved with the Peer Mentor Program or continuing your involvement with the Peer Mentor Program?
  2. What skills and attributes do you believe are necessary to be an effective Peer Mentor? In which of these areas are you particularly strong and why? In what areas do you need improvement and why?
  3. Think about your experiences during your first year of college. What were your most significant challenges? What experiences were most valuable for your academic, social, and personal development? How have these experiences prepared you for the role of Peer Mentor?

Part Four: Recommendation

Please list the name and title of a faculty or professional staff member (no undergraduate students) who will serve as an appropriate reference on your behalf. The reference should be able to address your qualification for this position. Please provide your reference with a copy of the recommendation form found online at All recommendations must be submitted by Friday, February 17. Your application will not be considered complete without a reference.

Name:  Title:

Phone:  How do you know this person?

Part Five: Agreement and Verification of Information:

I have read and understand the Peer Mentoring Program position description and responsibilities. By submitting this form, I affirm that the information which I have provided on this application form and all other application materials for the Peer Mentoring Program are complete, accurate, and true to the best of my knowledge. I give the Office of Student Retention permission to check my academic and disciplinary standing.

For future reference, how did you hear about this position?

Last Updated 8/30/12