Peer Education Application 2019

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* 1. Please fill out all of the fields.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Which location are you applying to?

Toledo

Columbus - Beechcroft

Columbus - City-wide

Columbus - Eastmoor Academy

Columbus - Kaleidoscope Youth Center

Columbus - Whitehall Yearling High School

Cleveland

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* 3. What is the best time to call you to schedule an interview?

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* 4. Why would you like to participate in the Peer Education Program? (2-3 sentences)

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* 5. Why do think you would be a good mentor to other teens at your school and in your community? (2-3 sentences)

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* 6. Based on your experience in your community, please share why you think a Teen Pregnancy Prevention Program is necessary in your school or community? (2-3 sentences)

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* 7. What days and times are you available to meet?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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* 8. What grade are you in?

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* 9. Class Schedule (if in a school-based program)

1st Period

2nd Period

3rd Period

4th Period

5th Period

6th Period

Other