Peer Mentor Application Form Mentor Application form First names: * Surname: * Date of birth: * Ethnicity Address: Town/city: Post code: Telephone: E-mail: Full & valid driving licence? * Yes No Own transport? Yes No Are you available for two or more hours per week? Yes No Do you speak any other languages? Yes No If yes, please state: Substance use history: * How long have you been dry/clean? * Do you have any disabilities or impairments that we need to be aware of? Yes No If yes, please state: Do you have any convictions? Yes No If yes, please state: Have you previously volunteered? Yes No If yes, please give details: Do you have any qualifications? Yes No If yes, please specify Work experience. Please list any previous roles (voluntary or paid): Please tell us why you would like to become a Bridge Mentor: * Hobbies/interests/skills: Comments: References: We require a reference to proceed with your application. Referees must be over 18 years old and not a family member. They can be a previous employer/voluntary organisation, leader or colleague of any groups you belong to, tutor/ lecturer etc. Referee's name: * How do you know this person? * How long have you known this person? Organisation: * Address: Telephone: Email: Next of Kin: Please give details below: Full name: Relationship: Telephone: Address: Submit If you are human, leave this field blank.
