Please fill out all the information on
both sides of this application and submit it to
Women’s
Services and Gender Resources at Holmes House 2nd Floor or send to
MSC #43.
If
a question does not apply to you please indicate by putting N/A in the space
provided.
Name__________________________________________________________________
Address_________________________________________________________________
Phone
Number_____________________ E-mail
address________________________
Major____________________________ Year (circle) 1st 2nd 3rd 4th 5th
1. How did you hear about the S.A.F.E education program?______________________
2. What topics are you interested in? (circle all that apply)
Health and Wellness Violence Prevention Diversity One
to One Mentoring
3. What role would you like
to play within the group? Rate in order
of interest: (1)
being very
interested and (5) not interested at all.
Performing
Vignettes/Skits _____
Facilitating Workshops/Leading Discussions _____
Publicizing/Marketing
Programs _____
Technical Assistant/Behind the Scenes _____
Program Assistant/Program Development _____
4. Briefly explain why you
would like to join the S.A.F.E. Educators group.
_____________________________________________________________________________________________________________
5. Are you able to commit to the 15hr
training? (If no, please explain)
_______________________________________________________________________________________________________________
6. Have you ever presented in
front of a large group of people? (If yes, please explain) ___________________________________________________________________________________________________________________
7. How do you relieve stress and/or take care of
yourself? Please explain. ________________________________________________________________________________________________________________________________________________
8. Please list any and all other extra
curricular activities you have been in and/or are currently involved with.
_______________________________________________________________________________________________________________________
9. Have you ever been on academic
probation? If yes please explain.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
10. Have you ever been arrested and/or been on
judicial probation? If yes please
explain. ________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list three references
that can be contacted.
________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________
Thank
you for filling out this application. We
look forward to working with you!
The
Whole Health Team 2004-2005
