Peer Mentor Referral Form

Thank you for your interest in the Peer Mentor Program. If you are a teacher, we suggest that you personally encourage the student to come meet with us in addition to making the student aware that you are referring him/her to us. Once the form has been received, the student will be contacted to schedule an appointment with a peer mentor. Please note that the student has the choice to decline to meet with a peer mentor.

Otherwise, if you are a student and would like help from the Peer Mentors, please fill out the Student Information section in the form below. We will contact you as soon as possible.

Referrer Information

Your Name:

Your Email

Your Phone No.

Your Department (if applicable)

Student Information

Student Name

Student ID

Reason for Referral

Please enter the code

Employee Website (The Nest) | Hawk Squawk eNewsletter | Alumni Membership | Complaints & Concerns | COVID-19 Information

© 2022 Umpqua Community College, 1140 Umpqua College Rd., Roseburg, OR 97470
Phone: 541-440-4600 | Toll Free: 800-820-5161 | Oregon Relay TTY: 711

UCC Non-Discrimination Statement.
UCC is an equal opportunity employer and educator.
Umpqua Community College is accredited by the Northwest Commission on Colleges and Universities.

Main Menu (Mobile)