Community Health Promoter Application

Diverse & Resilient’s 414ALL Community Health Promoters (CHPs) help reduce teen STI and pregnancy rates by making condoms more available, accessible, and acceptable through their own social networks. CHPs generally meet twice per month and are given a stipend to support their involvement. CHPs decide how much time they want to spend distributing condoms and are encouraged to do so in their existing social circles. CHPs also work to develop their own leadership skills along the way.

Click here for more information about the 414ALL Community Health Promoter position.

Basic Information
Name*
First Last
Birth Date*
MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code
Cell Phone Number*
Other Phone Number
Email Address
Referred By
First Last
Date Available*
MM slash DD slash YYYY
Education
High School
Graduation Date or Year in School
Technical School / College / University
Dates Attended
Degree / Major
References
How did you hear about this opportunity?
School / Work / Volunteer Reference Name
Please provide the name, phone number, & email address of an individual who could act as a school / work / volunteer reference.
First Last
School / Work / Volunteer Reference Phone Number
School / Work / Volunteer Reference Email Address
Personal Reference Name
Please provide the name, phone number, & email address of an individual who could act as a personal reference. This individual should be someone who has known you for two or more years.
First Last
Personal Reference Phone Number
Personal Reference Email Address
Involvement, Experience, & Goals
Involvement
Identify any projects or programs you have been involved with through your school or community that would show you can follow through with long-term commitments. You might include volunteer activities, church groups, sports teams, or school clubs that lasted at least one school year.
Experience
What experiences, skills, and / or attitudes do you have that would make you a great peer educator who is interested in making a difference in your community by talking to others about difficult subjects like sex and condoms?
Goals
What are some goals that you want to accomplish in the coming year, and how would involvement with Diverse & Resilient's 414ALL Community Health Promoter program help you to reach those goals? (Example: applying to a college or for an internship)
Additional Information
Is there anything else you'd like us to know?
Enter the following text to verify your submission.

Community Health Promoter Application

Basic Information

Education

References

Involvement, Experience, & Goals