Name:     I.D.#

Day Phone:     

Permanent Phone:

E-mail:

Best method for contacting you:

  Day Phone     Permanent Phone     Email

Local Address:

Permanent Address:

Number of Hours Enrolled:

Spring:     Summer:     Fall:

College Enrolled In:

Year in College:

How did you hear about the Peer Education Program?

Please list each Extracurricular Activity you are involved in:

Please list the names, addresses and telephone numbers of two (2) persons as a reference.  Please specify relationship, i.e. RA, Academic Advisor, Professor.

Reference 1

Reference 2

Why do you want to become a member of PEP?

Describe a previous experience/training you have had which would be helpful in your work with TU's PEP?

What do you believe to be the greatest health education needs of TU's Students?