Project SUCCEED Peer Mentoring Application

Please read carefully and complete the entire application. All fields must be completed in order for the applcation to be accepted. For additional information call (901) 333-4324.

Applicant Information

First Name Last Name Initial Banner ID Street Address City State County ZIP code Phone No E-mail Address Date Available Are you a US citizen? YES NO If not, do you have a permit to work in the US? YES NO

Are you currently a student? YES NO Do you have a criminal record? YES NO If yes, explain

Education

High School

School Name City State From To Graduation

Southwest

Campus From To Southwest GPA Total Credit Hours Earned

College/University

School Name Address From To Total Credit Hours Earned

References

(Please list three work related or personal references other than family members.)

Reference 1

Full Name Relationship Address Phone No

Reference 2

Full Name Relationship Address Phone No

Reference 3

Full Name Relationship Address Phone No

Other Information

Have you completed any developmental studies courses? YES NO

What were the courses and what grades did you receive?

What (if any) restrictions might affect your mentoring and tutoring assignments (i.e. health, family, or work)?

Why do you want to become a peer mentor?

LIABILITY RELEASE

I, by serving as a peer mentor with the Project SUCCEED program, do hereby release Southwest Tennessee Community College, its agents and representatives from any responsibility or liability that may arise in relationship to my mentoring duties. I also hereby consent for Southwest Tennessee Community College to use my name, likeness, or program participation for public relations purposes; I understand that I will not receive compensation for any such use.

DISCLAIMER

By checking this box, I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.