Peer Health Educator
Application Form 2016
Please answer all questions truthfully, thoughtfully, and thoroughly. Check your spelling & grammar.
Name:
Phone:
Is this a cell #? Yes/No
School Mailing Address/Local Address:
Permanent/Home Address:
Email:
Date of Birth:
Gender:
Student ID #:
GPA (Cumulative):
Year in School:
Expected Month & Year of Graduation:
Major(s):
Minor(s):
Total semester
hours completed
at end of Spring:
We check applicants’ student conduct records; please type your name following
the statement below to acknowledge this practice:
I acknowledge that my conduct history will be reviewed by the Assistant Director
Health Services, Health Education & Promotion.
.
1. Why do you want to be a Peer Health Educator?
2. What do you hope to achieve for yourself and others as a Peer Health Educator?
3. What knowledge, skills, interests and strengths can you bring to the Peer Health Education
Program?
4. Name three important health issues related to college students. Why do you feel these
issues are important?
5. What experience have you had working on a team, and what role do you typically play on a
team?
6. Please list your co-curricular and work responsibilities and, approximately, how many hours
per week you must dedicate to each. (For example: UMADD: 2 hrs/wk.)
If selected to be a Peer Health Educator, how will you manage these time commitments?
7. Peer Health Educators are expected to be positive role models. Describe how you would be
a positive role model to fellow UMD students.
8. How did you learn about the Peer Health Education Program?
References:
Please list two references below who can speak to your abilities to be successful as a Peer
Health Educator. References cannot be professional staff members or students (Peer Health
Educators) associated with the Peer Health Education Program. References should be people
who have supervised your work and can speak to your abilities and limitations as a leader or
employee. Friends who can provide character references are not as helpful as professors or
employers.
Reference #1:
Name
Relation to Applicant
(employer, professor, etc.)
Email Address
Phone Number
Reference #2:
Name
Relation to Applicant
(employer, professor, etc.)
Email Address
Phone Number
Email your completed application form to: livewell@umassd.edu
Applications must be emailed and received by: Monday, April 4th by 5 pm
Interviews will be scheduled for: Wednesday, April 13th