The PEERS Project Elkhart Central, Elkhart Memorial and Jimtown High Schools Teen Leader Application - COPY

The PEERS Project Application

Please fill out all the required fields.

Name*

First Name

Last Name

Date of Birth*

Age*

Gender*

Ethnicity*

T-Shirt Size*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Cell Phone*

Email*

How often do you check your email?*

Daily, Weekly, Monthly or Hardly Ever?

High School *

Your GPA*

Please use your last semester's GPA

Your Current Grade Level*

Male or Female (M or F)

Place of Worship (optional)

Facebook Profile

Please say None if you don't

Twitter Account

Please say None if you don't

Instagram Username

Please say None if you don't

Snapchat Username

Please say None if you don't

Other Social Media Site You Use?

Please say None if you don't

If you are working, who is your employer?

Name of Middle School you attended:*

How many days have you been absent this year?*

How many days have you been late to school this year?*

Have you completed your high school health class?*

yes or no?

If you have not completed your health class, when will you be taking it?

Will you be taking any honors or advanced placement classes next year?

yes or no?

Will you be involved in an internship, field experience, or attending the career center during the 2016-2017 school year?

If yes, please list the days/times this will take place

If needed, will you have transportation to drive to and from the schools for PEERS?

yes or no?

Please list the name of the school staff memeber or current PEERS leader that referred you to the program.

If you were not referred by someone, how did you hear about The PEERS Project?

I have been sexually active.*

yes or no

If you have been sexually active in the past, have you made a GENUINE COMMITMENT to abstain from sex from now until you are married?

yes or no

I have tried sexting.*

yes or no

I have smoked a cigarette.*

yes or no

I have drank alcohol.*

yes or no

I have tried a drug.*

yes or no

If you have said yes to any of the above, please tell us what you have learned from that experience:

Please sign below to show you understand what is required to be a peer leader for The PEERS Project of Indiana, Inc.

I understand what is required of me in being a leader for The PEERS Project. I understand that I must live by example, demonstrating my own personal commitment to making the right choices and serving as a positive role model. To represent The PEERS Project as a leader, it is my responsibility to follow the exact same principles I will be asked to teach younger students. I am committed to standing firm for my values and goals. I am planning for my future and everything I want to accomplish. I understand that my involvement in this program will end if:  I do not live up to the high standards and expectations  If my reputation/credibility could potentially jeopardize the integrity of The PEERS Project. Furthermore, if I partake in any risk behavior(s) - - including, but not limited to: sexual activity, sexting, drinking, smoking, or using a drug, it is my responsibility to turn in my materials and withdraw from The PEERS Project.

Student Signature

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Parent or Guardian 1 Name*

First Name

Last Name

Parent or Guardian 2 Name

First Name

Last Name

Parent 1 Cell Phone*

Parent 2 Cell Phone

Parent 1 Email*

Parent 2 Email

Please say none if not applicable

Parent 1 Place of Employment

Parent 2 Place of Employment

***References***
As part of the application process, we require two references. Preferred references include: an employer, a teacher or counselor, an academic or student organization advisor, a coach or someone else that has observed you in a leadership role. Please do not list family members or friends/peers that are your same age. Be sure to notify your references in advance that they may be contacted regarding your application.

Reference #1*

First Name

Last Name

Relationship to Applicant*

Reference # 1 Phone Number

Reference # 1 Email Address

Reference #2*

First Name

Last Name

Relationship to Applicant*

Reference # 2 Phone Number

Reference # 2 Email Address

In the space below, please clearly list the first initial and last name of your teachers or you many write down their school email address*

Before answering the following questions, please thoughtfully consider the rationale behind a peer facilitated program!

WHY are you applying for The PEERSProject?*

100 characters or more requried

What are you best known for at your school?*

What has being in high school taught you?*

If you had to guess, what percentage of your close friends are sexually active?*

If you had to guess, what percentage of your close friends "party" (drink, smoke or use drugs?)*

Are you or have you been in a dating relationship?*

yes or no

Whether you have or have not, what are boundaries in a dating relationship and do you feel they are necessary?*

If you could give ANY advice to a peer in regards to dating and sex, what would you say?*

There is a lot of speculation about colleges and employers requiring access to the social networks (Facebook, Twitter, Instagram, etc.) of their applicants. Do you see this as fair and reasonable or a violation of privacy? Please explain.*

If you had to rate the content on your own social networks on a scale of 1-10 (with 1 being extremely negative and 10 being extremely positive), what score would you give yourself? *

1-10

How long do you think is reasonable to date before engaging in sexual activity?*

What is a reasonable number of sexual partners throughout a lifetime?*

As you know, saliva swabbing is used for alcohol and drug testing at school, how would you feel if similar testing was a requirement to participate in PEERS? *

What does the saying “practice what you preach” mean to you? On a scale of 1-10 (with 1 being the lowest and 10 being the highest,) how important is that concept to you? Please explain. *

If you are selected for PEERS, you will have to leave class to teach at the middle schools. Do you see this is a pro or con to being in the program? Please explain.*

What negative things have you been asked to do/try because of peer pressure? Do you regret the choice(s) you made? *

Have you ever been curious about how drugs or alcohol make you feel?*

Have you personally encountered the use of drugs or alcohol?*

Please list the activities and sports that you are involved in (both in and out of school)*

What do you like to do for fun?*

What are the top 3 priorities in your life right now?*

What are 3 long-term goals you hope to accomplish in the future?*

Please write three words you feel your teachers would use to describe you:*

List any discipline issues you have had while in high school and what they were for:*

(referrals, ISS, suspension, etc.) if none please type none

***The following permission slips are for all involved parties including: Elkhart General Hospital, The PEERS Project, Inc., Elkhart Community Schools and Baugo Community Schools. These forms must be signed and returned as part of the application process***

I give my son/daughter permission to participate in The PEERS Project mentor program.

I give my permission for him or her to complete this PEERS mentor application and to be interviewed for The PEERS Project. I understand that my child will proceed through an application and an interview process in which direct questions will be asked regarding his or her thoughts, beliefs and behavior regarding sexual involvement and other risk behaviors such as: sexting, alcohol, tobacco and drug use. I further understand that if selected for the program, my child must attend a mandatory PEERS training session which will be held at Elkhart General Hospital.

I understand that if selected for the program my child will miss some regularly scheduled classes at the high school in order to teach the PEERS curriculum to eighth grade students at Northside, Westside and Pierre Moran Middle Schools as well as LIFE, alternative education. If my child will also be teaching/mentoring students in other grades/schools, again I understand that he or she will miss some additional regularly scheduled high school classes. I understand that my child will be working with the program coordinator and PEERS assistants from Elkhart General Hospital, the middle school health teachers and possibly other teachers during the abstinence/risk avoidance presentations. I know that transportation from school to school (from 9:00a.m. – 1:30p.m.) is the responsibility of the school system. In addition, I know that if my child is scheduled to teach the PEERS curriculum prior to 9:00a.m. or after 1:30p.m. he or she will need to provide his or her own transportation. When driving (instead of riding the bus), I understand that mentors are not allowed to ride together to/from their presentations (the only exception is siblings).

I further understand that in the middle school classroom (and possibly elementary or high school classrooms) my child will engage in and encourage age appropriate discussions and educational activities relating to early sexual involvement, healthy relationships, sexually transmitted infections, the link between drugs, alcohol, and sex, as well as teen pregnancy and parenthood. The PEERS curriculum consists of research-based information, games and activities, discussion questions, and video vignettes and focuses specifically on risk avoidance and goal setting.

By signing this permission slip (and the 3 that follow), I am giving my child permission to participate in The PEERS Project (and permission to drive to/from the assigned schools) throughout his or her high school years. I assume all risks and hazards incidental to participating, including transportation to and from program activities. I hereby waive, release, absolve, indemnify, and agree to hold harmless the organizers, officers, sponsors, and employees of The PEERS Project, Inc., Elkhart General Hospital and Elkhart Community Schools from any claim arising or from any injury to my child.

Please read this Parent Consent Form and the accompanying Release of Identifiable Information & Media Release forms carefully. If you wish to give consent, please complete and sign this Parent Consent Form. Mentor applications that are not accompanied by a properly signed and completed Parent Consent Form will not be accepted by The PEERS Project of Indiana, Inc. Students who are 18 years of age or older may complete and sign the Consent Form themselves.

By signing this form, I am giving The PEERS Project staff permission to communicate with the staff and administrators of my student’s school regarding services offered to my student by either entity. In addition, by signing this form, I am authorizing the exchange of documents and information between The PEERS Project and my student’s school, which is specifically defined below. I understand that all records and information regarding services is protected by the Family Educational Rights Privacy Act, which governs the exchange of confidential information.

It is understood that by authorizing the release of such information, it will be used for the sole purpose of providing services and coordination of services between The PEERS Project and my student’s school, thereby enhancing the services for my student. The exchange of information will be limited to the authorized staff of The PEERS Project and my student’s respective school.

The PEERS Project would like to publicize activities and events taking place in the program. As such, The PEERS Project seeks permission to use the following information, some of which may be considered personally identifiable information as defined and contemplated by Family Educational Rights and Privacy Act. The information The PEERS Project seeks to use includes first and last name, school name, location, voice, photograph, image, and/or likeness. This information, including the right and license to use any comments, quotes, or statements, may be published in electronic or other print media format including, but not limited to, The PEERS Project website and The PEERS Project Facebook page. It is important to understand that posting licensed material and identifiable information online presents potential risks, as The PEERS Project cannot control who may access such information.

I GRANT The PEERS Project permission to use my student’s, licensed material and identifiable information (as defined and limited herein), without payment or any other consideration.

I understand that if consent is revoked, The PEERS Project will discontinue publishing my student’s licensed material and identifiable information and will destroy or remove any existing copies in its possession. I understand that The PEERS Project requires ten (10) business days to process my request. I understand The PEERS Project is unable to recall any information that has been distributed, including images that may have been captured from The PEERS Project website(s). I understand this release only applies to licensed material and identifiable information in existence and that which may be created during one year after the date of this authorization. In the event The PEERS Project requires an additional license after expiration of this authorization, the organization will seek an additional release from the individual.

I hereby give permission for The PEERS Project to obtain information on:

PEER Mentor Application

Student Directory Information, which shall specifically include demographic data and contact information

Family Demographics

Academic Performance

Disciplinary Issues

Attendance

I grant the PEERS Project permission to contact me for information and fundraising purposes. At no time and under no circumstances, will The PEERS Project release, sell, or otherwise distribute information unless authorized to do so in writing or as required by law. This authorization to receive services from The PEERS Project and to exchange confidential and personally identifiable information shall remain in effect for the one calendar year from the date this authorization is signed by the parent or eligible student. I understand that this release may be revoked by me at any time with a written requested dated and signed by me, except to the extent that the PEERS Project has already acted in reliance upon this request.

Realizing that a number of educational opportunities exist outside the school building, most teachers desire to arrange for field trips or other outside educational experiences for their pupils during the school year.

We have found that the policy of requiring individual parental permission slips for each trip proves burdensome for both the home and the school. Therefore, we are asking that you sign one blanket release.

Mychild has permission to accompany The PEERS Project of Central High School on educational tours, events, and field trips during this school year (as well as throughout his/her high school career). We (I) understand that the group will always be accompanied by the teacher and generally by other adults, and agree that during such activity the Elkhart Community School’s representatives designated for supervision shall have full control and authority over the above-named student. I understand that the Guidelines for Good School Order and the Rules of Student Conduct will apply to this activity. I understand and agree that ElkhartCommunitySchools and the sponsor(s) will not be liable for the actions of the above-named student. In case we (I) prefer not to have our (my) child participate in some particular excursion, we (I) reserve the right to have him or her withdrawn and will notify the school in writing.

I give my permission to participate in The PEERS Project on various dates throughout the upcoming school year (as well as throughout his/her high school career) sponsored by: ElkhartCommunitySchools and Elkhart GeneralHospital and agree that the above named student may drive to/from this activity. Students will not be permitted to ride along with another student.

I agree that the Elkhart Schools’ representatives designated for supervision shall have full control and authority over the above-name student. I understand that the Guidelines For Good School Order and the Rules For Student Conduct will apply to this activity. I understand and agree that the ElkhartCommunitySchools and the sponsor(s) will not be liable for the actions of the above-named student.

In the event that any possible misconduct by my son or daughter would necessitate the involvement of any law enforcement agency, I understand and agree that the ElkhartCommunitySchools and sponsor(s) will not have any responsibility to resolve any legal obligations involving my child.

The above-name student and I understand it is the student’s responsibility to ask teachers for assignments and to make arrangements for all make-up work PRIOR to the field trip.

Parent Signature

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