Full Name:___________________________________________________  Age:_______________

Current Mailing Address:____________________________________________________________

City:_______________________________ State:______________ Zip Code:__________________

Home Telephone Number:__________________________________

Other Telephone Number(s) where you can be reached:________________________________

E-mail Address:______________________________________

Social Security Number:_______________________________ Date of Birth:__________________

Parent/Guardian, if under 18:_____________________________________

School Current Grade/Year Current GPA:_____________________

Demographic Information (Optional Questions):

I myself identify as:_____________________________________________________________

Sex: Female:____  Male:____ Other (Please describe):___________________________________

Race/Ethnicity:___________________________

Sexual Orientation:_____________________________

General Information:

1. Why are you interested in becoming a peer educator?

2. What special qualifications do you bring to this position?

3. Previous employment or volunteer experience:

4. Do you have any special needs (physical/medical) which we should be aware of?

5. Times/days you are definitely unavailable to work:

6. Extracurricular activities:

References:

Please name 2 people (at least one must be an adult) that we may contact for references.

Name:____________________________________________ Phone:_____________________

How does this person know you?______________________________

Name:____________________________________________ Phone:______________________

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TO THE PARENT OF A 16 OR 17 YEAR OLD APPLICANT:

You daughter/son is applying for a position as a Peer Educator and your signed consent is necessary for us to process this application. If you have questions, please call me at 389-3857. The application and consent form must be returned to JASMYN no later than___________: .

Sincerely,

Cindy Watson

Executive Director, JASMYN, Inc.

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PARENTAL CONSENT (16 and 17 year old only)

My daughter/son,__________________________ , has my permission to apply for and participate in the Peer Educator program sponsored by JASMYN.

Signature of Parent/Guardian:____________________________________ Date:______________

Printed Name of Parent/Guardian:___________________________ Phone Number:______________

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Please return this application to: JASMYN, Inc., P.O. Box 380103, Jacksonville, FL 32205 or Fax to 389-3089.