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Apply to be a Peer Educator

Please PRINT this application for your records AFTER filling in the information! If you have not been contacted within 7 days after sending this, please call 438-2053 as there may have been a problem with the electronic mailing.

Full Name: Male Female

YEAR: Freshman Sophmore Junior Senior Graduate Student

UID#:

Today's Date:

Campus/Local Address:

Campus/Local Phone (include area code):

E-Mail:

Permanent Home Address:

Permanent Phone Number (include area code):

Other E-mail address (if any):

*Please indicate that address where we may reach you over semester breaks. If none of the above, indicate below:

Campus/Local Address Permanent Address

Other:

Address:

Birth Date:

Graduation Date:

Major or Career Interest:

Overall Grade Point Average:

Number of credit hours planned for next semester:

How did you hear about Peer Education?

List the organizations you currently belong to and describe how you are involved in them:

Describe any experience you have in volunteer work or peer programs:

Why do you want to be a Peer Educator?

How much of a commitment can you fulfill? 1 Semester 1 Year and Maybe More

By checking this box and typing your name below, you confirm that all of the information that you entered is honest and correct.

Signature: Date:



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