Peer Helpers Student Application

First Name: ______Last Name: ______

Grade: Freshman Sophomore Junior Senior

Rate yourself in the following areas by placing an “X” under the box that you feel best describes you in relation to that area. Answer honestly, not everyone is perfect in every area.

Disagree Somewhat Agree Strongly Agree Agree

Willingness to help others.
Emotionally secure
Committed
Maintaining confidentiality
Accepted by your peers
Following Directions
Timely
Trustworthy
Tolerant of Others
Understanding
Concern for others
Helpful
Ability to listen
Could be a role model for others

What are your greatest strengths?

Are you willing to train for this position both after school and on weekends?

What is your strongest subject?

Are you willing to extent yourself to those who may not be of the same race, income or academic standards as yourself?

Peer Helpers have various areas rank the following in order of your interest:

____Peer Mediation

____Tutoring

____Mentoring

____Health Educator

____New Student helper

____Prevention Theater

Languages in which you are fluent ______

Are you willing to do presentations by yourself in front of a group?

Are you willing to do presentations with other people in front of a group knowing that you would have a part?

Answer the following questions

Yes No

Have you ever told a lie?
Have you ever stolen anything?
Would you keep $100.00 if you found it at school?
Have you ever allowed another student to copy from you?
Would you tell someone that they had something hanging from their nose?
Would you keep $5.00 if you found it at school?
Would you tell your friends parents if they were going to run away with their boyfriend/girlfriend?
Have you ever done any illegal substance?
Have you ever had alcohol?
Have you ever copied someone else’s homework?
Do you feel that everyone should abide by the same rules?
Can you keep a secret?

With in the school what are problems that you feel are not currently being addressed?

Would you be willing to take on these as a project?

Do you feel that you are part of a specific group? What group?

Would you be able to work with those who are direct opposite of you?

First Name: ______Last Name:______

In order to be a member of the Peer Helpers you must be willing to take an oath to abide by the code of ethics set by the National Association of Peer Programs.

From the time you turn in this application you are being interviewed. You know the standards set for Peer Helpers and the importance for this group to maintain a positive and strong influence on your peers. Regardless of your past your interview starts today.n Your actions and words in DHS and the community will affect the outcome of your selection process.

Please read the following and sign at the bottom. If you can not abide by these rules please put an “X” on the signature line and return it to me. All information that is obtained is confidential and only seen by Ms. Blandford.

A CODE OF ETHICS IS AN AGREEMENT AMONG THOSE WHO COMMIT TO THE PROGRAM AS TO THE NORMS THAT SHALL GUIDE THEIR BEHAVIOR DURING THEIR INVOLVEMENT IN THE PROGRAM.

Peer Helpers shall be people of personal integrity. NAPP believes peer helpers will:

1. Embrace the philosophy that peer helping is an effective way to address the needs and conditions of people.

2. Respect the individual's right to dignity, self-development, and self-direction.

3. Model positive behaviors and life choices (e.g., no substance use/abuse).

4. Embrace the concept of service to others for the good of the community.

5. Maintain confidentiality of information imparted during the course of program related activities with the exceptions of child abuse, sexual abuse, family dysfunction, psychotic behavior, harm to self and others, and drug and alcohol abuse.

6. Refrain from tackling situations for which they have no training and preparation (e.g., peer mediation, tutoring, etc.).

7. Recognize, report, and know techniques to deal with stated or implied threats to their emotional or physical well being.

By signing below I understand all information given to me in this application packet and know that I am to abide by the above standards through out the application process. However I am not to represent myself as a Peer Tutor until I have been accepted and have been told I can do as such.

Printed Name: ______

Signed Name: ______

Date: ______

Form: AA