Better Choices, Better Health

Peer Leader Training Application Form

 

Please fill out the following form to apply for the Peer Leader Training program. If you would prefer to print out your form and return it by mail, you can download the form and mail it to: Vintage/BCBH, 401 N. Highland Avenue, Pittsburgh, PA 15206.

 

Peer Leader Training Application Form (60 KB).

 

 

Referral Source
(if any):
What is your current age?
Under 60 60-70 Over 70
What is your gender?
Female Male
What is your race?
(Mark all that apply.)
American Indian or Alaska Native Hawaiian Native or Pacific Islander
White or Caucasian Asian or Asian-American
Black or African-American Other
Do you have a chronic condition?
Yes No

How would you get to the workshops?

Drive myself Take OPT or Access
Get a ride Don't know
Take the bus    
Are you willing to facilitate the workshop in areas other than your own neighborhood or township?
Yes No

If yes, please check all the areas you are interested in.

City only North suburbs
Mon valley East suburbs
South suburbs West suburbs
Are you prepared to facilitate a workshop within 3-6 months of your training?
Yes No
Are you comfortable with the idea of public speaking or facilitating groups?
Yes No

Are you willing to follow a structured and set curriculum in order to ensure that the program is followed in the correct way?

Yes No
Do you consider yourself to be someone who practices healthy behaviors in your own life?
Yes No

Have you taken the Better Choices, Better Health workshop as a participant?

Yes No
Briefly describe why you would like to become a Peer Leader:
Please check this box to verify that you are a human using this form, not a robot.
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