PEER HELPER APPLICATION



2015-2016 PEER HELPER APPLICATIONThis application must be completed, signed by a parent, and returned to Mrs. Jamie Burt, Peer Helper Sponsor, at Fairhope High School by Friday, March 27th.Acceptance is based on a point system, which includes scores from the following: completed application including signatures; open-ended response; ratings from teachers and current Peer Helpers. The final selection will be made from students with high application scores, regular attendance, high interview scores, and few disciplinary referrals. You will be notified of your acceptance or denial by the end of this plete Steps 1-6.1. Personal Information: Please complete the following information: (PRINT)Name: ___________________________________________ Current Grade Level : ________HR Teacher: ______________________________Parent/Guardian name: _____________________________Daytime #: _________________2. List your extra-curricular activities.3. Background Information: Please answer the following questions making explanations where needed.a. Were you a peer helper in intermediate/middle school? _____ If so, where? ____________________Do you have excessive absences? _______ If so, explain. ____________________________________c. Have you ever failed a class? ________ If so, what class and when? ___________________________d. Did you have any discipline referrals this year? _________ If so, explain. _________________________________________________________________________4. Confirmation. If chosen as a peer helper, I understand thatI must participate in required peer helper training & attend the JCMF Rodeo in Foley this August.I must set a positive example for my peers by being positive, accepting, supportive, and helpful. I must abide by the criteria listed on the peer helper contract and the National Association of Peer Programs Code of Ethics (on back of contract, please read & sign)Your signature: ___________________________________ date: ________________Parent/Guardian signature ________________________________date: ________________5. Open Ended Response: On a separate sheet of paper in 100-150 words, explain your desire to be a peer helper and your strengths, which would allow you to serve as an asset to the program. (This is a great part of your score, so take this seriously. i.e. more than “I want to be a peer helper because I want to help my friends and peers.)6. Interview: If you’re notified that your 1st round application scored high enough to make the first selection, you’ll need to schedule an interview for the final selection process. We will contact you about this.045085For office use only:Score ______Disc. _____ Att. _____ Grades _____Final Approval _____00For office use only:Score ______Disc. _____ Att. _____ Grades _____Final Approval _____ ................
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