Peer Educator Interest Form

Gender

Age

Phone

Are you in school?

Year In School

Do you use social media? Check all that apply.
FacebookTwitterInstagramSnapchatPinterestVine
Other

Would you be interest in participating in any of the following? Check all that apply.
Service Learning Team/GroupPeer EducatorYouth Advisory Board

Would you be interested in telling your peers about a program like this?
YesNo

Why or why not?

Do you have any special skills that would be an asset to the program?

What days and times of the week would you be available to meet? Check all that apply.
Monday 4 pm - 6 pm 6 pm - 8 pm
Tuesday 4 pm - 6 pm 6 pm - 8 pm
Wednesday 4 pm - 6 pm 6 pm - 8 pm
Thursday 4 pm - 6 pm 6 pm - 8 pm
Friday 4 pm - 6 pm 6 pm - 8 pm
Saturday MorningMid-DayAfternoon
Sunday MorningMid-DayAfternoon

How did you hear about InterAct?

Would you like for us to contact you?
YesNo

If yes, how?