Application for Membership

St. Peter’s College - Center for Personal Development

Peer Education Program - Application

Please print, fill out and return to Liz Russo in the Center for Personal Development,

located in Henneberry Hall, 3rd Floor (104 Glenwood Ave).

Name: __________________________________________________

(Campus) Address: __________________________________________________

(Campus) Phone: __________________________________________________

E-mail: __________________________________________________

(Home) Address: __________________________________________________

(Home) Phone: __________________________________________________

Graduation Date: __________________________________________________

Major: __________________________________________________

How many credits do you plan on taking next year? Fall _________ Spring ___________

Do you work? ______________ How many hours each week? ___________________

Have you participated in a Peer Education program? ______________________________

If yes, describe: __________________________________________________________

_______________________________________________________________________

Please list any related paid or volunteer work experience:

_______________________________________________________________________

List any hobbies, interests, or special skills:

_______________________________________________________________________

List your extra-curricular activities while in high school or college:

_______________________________________________________________________

Why would you like to be a Peer Educator? (Include any specific skills you would like to develop):

_______________________________________________________________________

Are there any areas that would be of special interest to you as a Peer Educator

(e.g., drug/alcohol use, AIDS, date rape, diversity, etc.):

_______________________________________________________________________

Substance Use Agreement

I, _______________, understand that as a Peer Educator I am a role model to the other students at St. Peter’s College. I also understand that my actions reflect on the Peer Education Program and all the people involved in the organization. The philosophy that Peer Educators have concerning alcohol use is that, if I choose to drink, I will do so responsibly. Therefore, I am willing to sign this contract stating that:

1. I will not be intoxicated in public.

2. I will not use illegal drugs.

3. I will not drink and drive.

In addition, I understand that the Center for Personal Development staff encourages me not to smoke.

These guidelines will be true as long as I am a Peer Educator. If I see or hear of another Peer Educator breaking this contract, I will attempt to speak with him/her and, if necessary, speak to a counselor at the Center for Personal Development. If I break this contract, I expect to be put on probationary status or be dismissed as a Peer Educator.

Peer Educator Signature: _________________________________ Date: _____________

Address: _________________________________________________________________

Peer Education Advisor Signature: __________________________ Date: _____________