Peer Mentor Application Form
Name: _________________________
Student Number: ____________________
Programme of Study: ______________________
Year: ________________________
1) Please state why you would like to become a peer mentor:
2) In your opinion, what qualities and skills do you have that could be used to support a
mentee?
3a) Please select, from the list below, areas that you feel confident in offering support to a
mentee. (Please tick any that you feel apply).
Report Writing
Essay Writing
Referencing
Presentation/Communication skills
Planning/Time Management
Exam/Revision Techniques
Orientation of the university
Helping new students to settle in
(i.e. familiarising students with the university)
English language skills;
assisting with speaking skills
assisting with written skills
(i.e. being a contact and a friendly face)
Numeracy skills
Research skills
IT skills
3b) Please state below any module/s (if applicable) that you are confident with and how
your experience may benefit your mentee:
Module name/s:
3c) Please indicate if you have any preferences regarding your mentee:
(please tick any that apply)
Male
Female
Similar age
Mature student
I have no preferences
4) What consideration have you given to your future career/post graduate education?
5) Supporting Reference (from a University of Bolton member of staff):
Name:
Signature:
Position:
Date:
6) Further information required from prospective peer mentors:
To ensure that the Peer Mentor Co-ordinators fully support every student involved in the
peer mentoring scheme, and take students’ individual needs into account, we would be
grateful if you could confirm the following: (please tick as appropriate)
1. Do you consider yourself to have a disability?
Yes
No
(Any disclosures, as indicated above, would be discussed in confidence and handled
according to the university’s guidelines).
2. Are you registered with the Disability Service? Yes
No
Peer Mentor Signature: ………………………………………………………….Date: .........................
Please return this form to your Peer Mentor Co-Ordinator, who is also the Student Liaison Officer for your
Faculty, thank you.
OFFICE USE ONLY:
Candidate Interview date: ............./...../........................
Outcome: Successful Unsuccessful (please circle)
Referral date if unsuccessful: ....../...../..........................
Referred to: ..................................................................
Co-ordinator Signature: ........................……….............
For CRB: Student is 18yrs or over? Yes/No (please circle)
Student is ‘current’? Yes/No (please circle)
Student is an Alumni member? Yes/No (please circle)