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(Please type or print in ink)

1. _________________________________________________________________________
  (Last Name)         (Mr./Ms.)         First Name            Middle Name


2. Social Security Number: ____________________


3. On/Off Campus Address: ___________________________________________________
                           P.O.Box#          Room#             Bld.#
   _________________ _____________________________________________________
  (County) City State Zip Code


4. Local Telephone Number: _______________________ or ________________________
   Home Telephone Number:  _______________________ or ________________________


5. E-mail address: __________________________________________________________


6. Classification: __ Freshmen __ Sophomore __ Junior __ Senior 
   Major:______________


7. What is your cumulative grade point average? __________


8. Who is your Academic advisor? ______________________ Ext.# _________________


9. How many credit hours are you pursuing this semester? ____________


10. Please list all campus /community organizations you are currently
    or were previously involved in:
    ______________________________ ___________________________________
    ______________________________ ___________________________________
    ______________________________ ___________________________________
    ______________________________ ___________________________________


11. Why do you wish to become a Peer Educator on your campus? __________________
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________


12. What are your career goals and objectives? _________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________


13. Do you have any past experiences on HIV/AIDS or drug and alcohol prevention?
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________
  

14. What past experiences have you had as a peer leader or mediator? ___________
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________
 
  
15. Have you been involved or participated on prevention program or groups? 
    __________________________


16. If yes to #15, which groups or program? ____________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________


17. Please describe what qualities do you have that will make you a good 
    peer leader: 
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________
  ______________________________________________________________________________



  Please return application as soon as possible to:
  Ms. Lauresa Moten, Director
  Tel. (410) 651 - 6385 Fax. (410) 651 - 6386