Scan/Email application to:

blake.mackie@ppmchoice.org

Fax Application to:
313-831-4699

Mail/Drop off application to:
Community Outreach Educator
Planned Parenthood Detroit Health Center
4229 Cass Ave.
Detroit, MI 48201

If you have any questions, call
Blake Mackie
at 734-926-4841

APPLICATIONS DUE BY:
May 31, 2014

Planned Parenthood Mid and South MI
Peer Education Program Application

Planned Parenthood Mid and South Michigan (PPMSM)
Planned Parenthood Mid and South Michigan (PPMSM) delivers vital reproductive health care (like
pregnancy testing, birth control, STD testing and treatment), sexuality education, and information to
thousands of women, men, and teens across the state of Michigan.

Planned Parenthood is a respected leader in educating Americans about reproductive and sexual health.
We deliver comprehensive sex education that empowers women, men, teens, and families to make
informed choices and lead healthy lives. Planned Parenthood is proud to provide young people with
honest sexuality and relationship information to help reduce high rates of teen pregnancies and sexually
transmitted infections. Thousands of youths and adults participate in PPMSMs educational programs
every year. One way Planned Parenthood Mid and South Michigan offers education is in partnership
with the young people in our Peer Education Program.

Summary of Peer Educator role at PPMSM
A PPMSM Peer Educator is responsible for serving as a confidential, non-judgmental resource for peers
on sexuality and reproductive health, providing accurate information and referrals; serving as a sexual
health information resource to youth in their communities through one-on-one interactions,
presentations in schools and in the community, and other PPMSM events as assigned.

Essential Functions:
Peer educators will attend a mandatory, interactive, informative, and fun 40-hour training.
Training topics cover different issues teens face such as: Abstinence, Healthy Relationships,
Sexual Orientation, Gender Identity, sexual decision-making, Sexually Transmitted Infections,
HIV/AIDS, Contraception, Teen Pregnancy, and much more.
Attend weekly meetings to discuss future presentations and projects and conduct continuing
education.
Serve as a confidential, non-judgmental resource for peers on sexuality and reproductive health,
providing accurate information and referrals.
Encourage teens to talk to their parents or other trusted adults about sexual health and healthy
relationships whenever possible.
Support peers in navigating local social service agencies to help them access needed care.
Conduct community outreach to youth, potential patients and community members through
advocacy activities such as youth-led workshops, attending community meetings, tabling at
health fairs, etc. to increase community awareness of PPMSM services and of comprehensive
sex education laws and policies.
Provide reproductive and sexual health education programs to community groups, parents and
professionals as assigned.
Deliver presentations on sexuality and reproductive health in various settings.
Promote STD testing and treatment resources in the community.
Promote pregnancy prevention resources in the community.


Qualifications
Ages 13-19
Minimum of a one-year commitment
Demonstrate healthy decision-making skills and behaviors while serving as a positive role model
for their peers
Ability to respect value systems different from ones own. Student must be comfortable meeting
new people and working with other students from surrounding schools.
Willingness to provide accurate, non-judgmental, and confidential information and referrals at
all times. Ability to support Planned Parenthoods mission.
Time management is very important. Peer Educators are expected to make their program
participant tasks and duties a priority.
Student must come with an open-mind and eagerness to learn about healthy sexual decision-
making.
Peer Educators are responsible for their own transportation to and from training, weekly
meetings, events, workshops, and presentations.
Student must feel comfortable being approached by other members of the community once
they are known as Planned Parenthood Peer Educators. The expectation is that Peer Educators
be an advocate for healthy sexuality within their communities.
Parent/Guardian permission to participate in the program unless individual is over the age of 18.

Benefits of being a Peer Educator:
Gain public speaking, empathy and listening skills
Opportunities to travel for national and state wide events
Looks great on job and college applications
Gain professional development, leadership and time management skills
Thorough training in topics related to human sexuality and teen health
Experience providing youth-friendly health care
Network with city, county, state, and national organizations and potential future employers


Please sign below to confirm that you have read and understand the above information:

Applicant Name (please print): ______________________________________

Applicant Signature: _______________________________________________ Date:________________












Personal Information

Name


First Middle Last
Date of Birth
(you must be 13-19 to apply)


Day Month Year
Address



Street Unit/Apt# City State Zipcode
Phone Number


Main Number Second Number where we can reach you
E-mail


What School (if any) do
you attend?

Current
Grade
Circle one:

9
th
10
th
11
th
12
th


Emergency Contact Information

Name


First Middle Last
Address


Street Unit/Apt# City State Zip code
Phone Number





Main Number Alternate Number


Scheduling Information

Are you willing to commit to all days of a 40+ hour training, weekly meetings and related events on
behalf of Planned Parenthood of Mid and South Michigan throughout the school year? _________

What times of the week are you available during the summer?

Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays
(Ex. 3-5pm)






What times of the week are you available during the school year?

Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays





When is/was your last day of school?__________________________
Please list any after-school activities you will be (or anticipate being) involved in during the school year.
There may be limited flexibility and arrangements made around school activities with coordinators
permission. Please note that Peer Education Program activities will be expected to be prioritized.

Name of Activity Season/Dates Days/Times of the week













Please list any employment/volunteering you will have during the school year.

Name of Employer/Supervisor Duties/Responsibilities Days/Times of the week














Essay Questions
Please answer these questions to the best of your ability. You are allowed to attach additional pages or type your
responses and attach the printed page.

1. Why should you be selected as a Peer Educator? Be specific.







2. What do you think about STDs and/or teen pregnancy in your community? Be specific.







3. List any skills or special training you have that could help you be a strong candidate for this program.


4. If selected, how will you demonstrate your commitment to the Peer Education Program?







5. We expect each Peer Educator to fully participate in the program. What does full participation mean to you?







6. Tell us about a time when you had to demonstrate leadership ability (be specific)?





Applicant Statement

I certify that all information I have provided in order to apply for and secure program participation with
Planned Parenthood Mid and South Michigan (PPMSM) is true, complete and correct.
I understand that any information provided by me that is found to be false, incomplete or
misrepresented in any respect, will be sufficient cause to (a) cancel further consideration of this
application, or (b) immediately discharge me from the program, whenever it is discovered. I expressly
authorize without reservation, Planned Parenthood Mid and South Michigan, its representatives,
employees or agents to contact and obtain information from all references (personal and
professional), employers, public agencies, licensing authorities and educational institutions and to
otherwise verify the accuracy of all information provided by me in this application, resume or interview.

I understand that PPMSM does not unlawfully discriminate in program participation and no question on
this application is used for the purpose of limiting or excusing any applicant from consideration for
participation on a basis prohibited by applicable local, state or federal law. In consideration for program
participation with Planned Parenthood Mid and South Michigan, if accepted, I agree to conform to the
rules, regulations, policies, and procedures of Planned Parenthood Mid and South Michigan at all times
and understand that such compliance is a condition of participation. I understand that due to the
scope of Planned Parenthood Mid and South Michigans mission, attendance and punctuality are
considered essential requirements of every position at Planned Parenthood Mid and South Michigan
and that poor attendance and tardiness will result in disciplinary action.

Please sign below to confirm that you have read and understand the above information:

Applicant Name (please print): ______________________________________


Applicant Signature: _______________________________________________ Date:________________
Planned Parenthood Mid and South Michigan
Peer Education Program Application
Adult Reference Form #1
Each applicant must provide at least 1 adult referral. These CANNOT be family members or relatives. We suggest
teachers, coaches, employers, supervisors for volunteer work, guidance counselors, etc.
Applicants Name______________________________

References Name______________________________ Reference Phone/Email______________________

How long have you known the applicant?_______________________________________________________

In what capacity?___________________________________________________________________________
The above-mentioned applicant is being considered for participation in Planned Parenthood Mid and South Michigans
Peer Education Program. A Peer Educator is responsible for providing leadership and education to their peers about
sexual health. Peer Educators are responsible for working respectfully with diverse audiences in their community, and
commit to raising awareness about sexual health topics like teen pregnancy, STDs/HIV, rape and dating violence, and
LGBTQ issues. Please rate them in all areas below.
Academic Performance
Attendance
Follow Through
Work Ethic
Motivation
Critical Thinking Skills

Problem Solving Ability
Written Communication
Oral Communication

Preparation for Class
Excellent Good Fair Poor N/A
Leadership Skills
Independence
Integrity
Social Maturity

Respect for Adults

Respect for Peers

Teamwork Skills
Concern for Others
Social Responsibility

Civic Engagement
Please offer any additional comments concerning this
applicants ability, character, and suitability for admission
into the Peer Education Program.
Signature__________________________________________________________ Date__________________________
After completion, tri-fold, tape this form shut on all sides, then return it to the applicant. Alternatively, you may send
the reference directly to the Peer Education Program Coordinator, Blake Mackie:
Scan/email: blake.mackie@ppmchoice.org, fax: 313-831-4699, mail/drop off:
Community Outreach Educator
Planned Parenthood Detroit Health Center
4229 Cass Ave.
Detroit, MI 48201
Applications are due by May 31, 2014. Thank you for taking the time to complete this form. Upon receipt, Planned
Parenthood Mid and South Michigan may contact you with any additional follow-up needs. Your genuine
recommendation is greatly appreciated. If you have any questions, please call Blake at 734-926-4841.