If under 18 years old must complete the form with their parent/guardian
Program Service Dates: September 1st – July 31st
Complete this form to request a Student Peer Mentor or Peer Leader. The form must be fully signed and submitted to be received by our team. During limited service times, a team member will contact you for "speed mentoring" support.
To participate in the mentoring program and remain assigned to a student peer-mentor, you must agree to the following program requirements:
1. Be taking classes at Broward College either full time or part time this academic year
2. Meet often with your peer leader mentor at least once per month for a minimum of 1 semester
3. Take a campus engagement or program survey at least once during the school year
4. Actively engage and keep your Peer Mentor up to date any challenges you are facing, the success and progress you are accomplishing.
*Please contact us at peermentoring@broward.edu for any questions or concerns. Important: this is NOT the application for an AmeriCorps "PAID" peer mentor position. If you want to apply to "become a peer mentor", Please Click Here.
Mentee Application Form
Peer Mentoring Privacy Notice | Consent Agreement
Securing Your Data Secure Storage – PeerForward and Broward College maintain reasonable physical, electronic, and procedural safeguards to protect personal information about you. Employee and Contractor Access to Information – PeerForward limits access to personal information about you to employees and contractors who we reasonably believe need to have that information to provide support to you or improve PeerForward programming.
PRIVACY NOTICE As a reminder, PeerForward and Broward College respect the privacy of others and takes steps to prevent unauthorized access to data on its systems. PeerForward does not sell or provide any data received from applicants to any third party for direct marketing or other unrelated purposes. In addition, it will not transfer applicant data to any outside party other than contractors, consultants, or others working with PeerForward on its programs. You consent to us using your information for research purposes, such as analyzing aggregated data to identify factors that influence the likelihood that a student will obtain a degree/certificate from the college. You consent to your personal information being shared by PeerForward with contractors, consultants, and others working with PeerForward on its programs.
Media Release and Consent Agreement The parties hereby mutually agree to the following terms of release and consent: PeerForward desires to use the below-identified materials in connection with the publication and distribution of materials, in various media, regarding and/or promoting PeerForward, its activities or accomplishments. Video or film material incorporating the applicant’s name, image, likeness, voice and/or spoken or written words. Photographic materials incorporating the applicant’s name and/or image. Telephonic or other recorded, electronic or digital materials incorporating the applicant’s name, voice and/or spoken or written words. Printed materials incorporating the applicant’s name, likeness and/or image. Web-based or other electronic or digital materials incorporating the applicant’s name, image, likeness, voice and/or spoken or written words. PeerForward and any of its subsidiaries, affiliates, representatives or agents shall have the right to reproduce, publish, broadcast or otherwise use, throughout the world, in any medium (including, without limitation, print, radio, television, web or other online or electronic media), the above identified materials, or any portion or derivation thereof, in connection with the discussion or promotion of PeerForward or any aspect of its program. Such rights shall include the right to reproduce, in whole or in part, and the right to create derivative works. All materials prepared by PeerForward that incorporate, consist of, or include the applicant’s name, image, likeness, voice, words or any portion of above identified materials, including, but not limited to any copyrights or other intellectual property rights shall belong to PeerForward and PeerForward shall be the author for all purposes.
I hereby authorize BROWARD COLLEGE and those acting pursuant to its authority to: 1. Record my likeness and voice on a video, audio, photographic, digital, electronic or any other device or medium; 2. Use my name in connection with these recordings; and 3. Use, reproduce, exhibit or distribute in any medium (including but not limited to, print publications, video tapes, CD-ROM, Internet, social media, or any other medium) these recordings for any purpose that BC, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts. I release BROWARD COLLEGE and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of BROWARD COLLEGE, and that I will not receive any compensation for the use of such recordings. I have read and fully understand the terms of this release.
FERPA Release of Student Information In accordance with the Family Education Rights and Privacy Act of 1974 (“FERPA” or the “Buckley Amendment”), by signing this PeerForward form, I consent to the release of my academic, financial aid, and related college records to PeerForward staff and/or designated representative(s) by my post-secondary institution. I also consent to the release of academic, financial aid, and related college records by PeerForward to its partners or designated representative(s) to support my college success and/or for program improvement. This includes personally identifiable student information to be released to PeerForward staff and/or designated representative(s). The information to be released includes but is not limited to: FAFSA form submission and completion, class registration and course load data, academic data, participation in college activities, and utilization of college resources. The consent and authorization to release education records shall remain in effect until written revocation from me is received by my post-secondary institution and PeerForward. My institution and PeerForward shall have a reasonable time to comply with any such revocations. Any revocation shall not affect disclosures made to or by PeerForward prior to receipt of any such written revocation.
I understand further that:
• I have the right not to consent to the release of my education records
• I have the right to review such records upon request
• I have the right to request changes or deletions to items with I believe to be inaccurate and in the event a change or deletion is rejected, I have the right to place a statement in the record explaining my view of the circumstances.
The Peer Mentoring program will aim to fulfill match requests but may not always be able to meet a specific demand or request.
By Signing up for this Service, I Commit to:
• Actively participate in the mentoring relationship by attending scheduled meetings and responding to my mentor’s communication in a timely manner for at least 1 semester.
• Take initiative in setting personal and academic goals and working toward them with my mentor’s support.
• Be open to feedback and willing to engage in meaningful discussions to enhance my college experience. I have read the information in this form.
