Become a Peer Mentor
Name: Banner ID:
Campus/Local Address: E-mail:
Cell Phone: Home Phone:
Class year in fall 2012: Cumulative GPA:
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.
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 www.brockport.edu/secondyear/peermentor. All recommendations must be submitted by Friday, February 17. Your application will not be considered complete without a reference.
Phone: How do you know this person?
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
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