PEER SUPPORT PROJECT

APPLICATION FORM
Closing date: Tuesday 2nd of May 2017

First Name Family Name

Email Age Gender

M F

Term Address including Post Code

Mobile Phone Number UK Home Phone Number

May we leave a message on this number if we need May we leave a message on this number if we need to
to contact you? Yes No contact you? Yes
No
Country of Origin:
UK EU Non EU

Name of Department

Accounting Government Management Science Group

Anthropology Industrial Relations Managerial Economics and
Economic History Information Systems & Strategy Group
Economics Innovation Group Mathematics
Employment Relations & Institute of Social Media & Communications
Organisational Behaviour Psychology Methodology
European Institute International Development Philosophy, Logic & Scientific
Finance International History Method
Gender Institute International Relations Social Policy
Geography & Environment Law Sociology
Management Statistics
Other:

Programme of Study: Duration of Course

From: To:

Degree:
Undergraduate PhD Summer School
Masters General Course Other
Do you have a disability?
Yes No
If yes, how would you describe the disability?

We are committed to meeting the needs of students with disabilities, and wish to know if we need to make
additional arrangements for you. Please contact us in advance, if possible, to let us know of any arrangements
that you may require, or specify here:

Please describe your ethnic origin.

This information is only used for statistical purposes
Asian or Asian British Black or Black British Mixed - White & Black
Indian Caribbean African
Asian or Asian British Black or Black British Mixed - White & Asian
Pakistani African Irish Traveller
Asian or Asian British Other Black background White
Bangladesh Mixed - White & Black Other Mixed background
Other Asian background Caribbean Other Ethnic background
Chinese Prefer not to say

The training programme for the Peer Support Programme runs for six full days starting on Tuesday 30th of
May and finishing by Friday the 16th of June 2017. Attendance at all the training sessions is mandatory for
students who wish to become Peer Supporters. We will be able to confirm the final training dates at
interview.

Supervision meetings are held every two weeks during term time. This is a space for Peer Supporters to
discuss issues that arise whilst supporting others. Attendance at these sessions is compulsory. It is essential
you attend supervision. You cannot be a Peer Supporter if you do not attend supervision.

I confirm that I am available to attend all of the training dates required for the Peer Support
Programme as indicated above.
I confirm that I agree to attend all Peer Support supervision sessions throughout the year.

Yes No
Please sign your name below

Signed: Date:
(or type your name if submitted electronically)
1. Please tell us what has motivated your interest in volunteering for the Peer Support Project:

Acquire skills
2. Please tell us something of your own background and identity that you think will help you
in learning to become a Peer Supporter:

Army
Church group

3. Please tell us a bit about some issues/difficulties youve struggled with in your life and what
helped you:

Thank you for your interest, we look forward to receiving your application. If you are completing this electronically,
please save it first and then email it to us as an attachment. Alternatively, please post it or bring it in to our office.
Closing date: Tuesday 2nd of May 2017.

LSE Student Counselling Service KSW 5.07 20 Kingsway