Apply to be a PEER Ambassador – Center for Youth and Family Advocacy

Please complete the following application to become a PEER Ambassador.

The application should be completed by students and signed by parents before submission.

There is no cost for PEER Ambassador training.

If you have any questions, please contact CYFA at contact@cyfadvocacy.org

Become a PEER Ambassador

"*" indicates required fields

Name*

First Last

Name you prefer to be called*

Phonetic pronunciation of your name*

Preferred pronouns*

Date of Birth (mm/dd/yyyy)*

Ethnicity

Grade

Please enter a number from 1 to 12.

School Name

Email*

Phone*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian Name*

First Last

Relationship to student*

Parent/Guardian Email*

Address (if different from the student)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

The following statements must be completed by the student.

How did you hear about the PEER Ambassador Program?*

Why are you interested in becoming a PEER Ambassador? (100 word maximum)*

What is the most important thing you would like to share about yourself? (100 word maximum)*

Emergency contact name*

First Last

Emergency Contact Phone*

Student Signature*

Parent/ Guardian Signature*