TRIO/SSS Peer Tutor/Mentor Application

 
Please complete the following fields:
First Name *
Last Name *
Student ID Number *
Social Security Number
Permanent Address
Permanent City
Permanent State
Permanent Zip
Permanent Phone
Are you presently working?
If you are working, who is your present employer?
Phone Number of Present Employer
When can you begin working?
Name of Parent(s) or nearest relative who can be contacted in case of emergency:
Phone Number of Emergency Contact
Are you a freshman or a sophomore?
What is your major?
What is your overall GPA?
How many semesters have you completed?
What academic and/or related activities are you involved in?
Which classes are you willing to tutor in?
List any experience, education, or training that you have attended or completed that would relate to tutoring.
List your employment history (past three years- full time, part time, or temporary). Start with your present or last position.
List any college or community organizations in which you are a member or involved in. Also indicate if you have held any position of leadership or received any awards from the organizations you listed.
List three references who have knowledge of your academic ability and potential for being a tutor. Two of your references have to be instructors at PRCC who teach the classes that you want to tutor in. The other reference can be another instructor, personnel from PRCC, or another person who can attest to your ability to work as a peer tutor or mentor. Family members or personal friends are not allowed. 
Reference 1's First and Last Name
Reference 1's Phone Number
Reference 1's Email Address
Reference 2's First and Last Name
Reference 2's Phone Number
Reference 2's Email Address
Reference 3's First and Last Name
Reference 3's Phone Number
Reference 3's Email Address
Have you ever been found guilty of a criminal offense, as a result of trial, entry of a plea of guilty, or a plea of nolo contendere?
Please check what days and times you are available to work.
Monday
8:00 - 9:00
9:00 - 10:00
10:00 - 11:00
11:00 - 12:00
12:00 - 1:00
1:00 - 2:00
2:00 - 3:00
3:00 - 4:00
4:00 - 5:00
Tuesday
8:00 - 9:00
9:00 - 10:00
10:00 - 11:00
11:00 - 12:00
12:00 - 1:00
1:00 - 2:00
2:00 - 3:00
3:00 - 4:00
Wednesday
8:00 - 9:00
9:00 - 10:00
10:00 - 11:00
11:00 - 12:00
12:00 - 1:00
1:00 - 2:00
2:00 - 3:00
3:00 - 4:00
4:00 - 5:00
Thursday
8:00 - 9:00
9:00 - 10:00
10:00 - 11:00
11:00 - 12:00
12:00 - 1:00
1:00 - 2:00
2:00 - 3:00
3:00 - 4:00
Authorization for Faculty Reference and Release of Information
I hereby authorize investigation of all statements contained in this application. I certify that such statements are true and understand that misrepresentation or omission of facts called for in this form is cause for termination of employment without notice. I also authorize the Student Support Services/TRIO Director and/or her designee to contact the references listed on my application for comment on my academic proficiency, personal/educational attitudes, and/or supporting qualifications. I authorize this reference check and the giving and receiving of the above information necessary to apply for a Peer Tutoring/Mentoring position in Student Support Services/TRIO. I realize that this information will be treated as confidential and release from liability any person giving or receiving such information. I have read and understand the above.
Applicant Signature *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number: