Peer Mentor Application
*First Name:
*Last Name:
*Street Address:
*City:
*State:
*Zip:
*Home Phone #:
Cell Phone #:
*Email Address:
*Password:
*Confirm Password :
*Age:
*Gender:
*Type of Disability:
*Date of onset of Disability:
(mm/dd/yyyy)

*Educational Level:


Work Experience:
Hobbies/Interests/Clubs:
*Do you have any previous Group or Leadership experience?
If yes, please explain
REFERENCE
Work or School Personal Medical (Rehab Physician or Therapist)
*Name:


*Phone #:


*Relationship:


Please List your Availability
MON
TUE
WED
THU
FRI
Photo
 
* I would like to be considered as a Peer Mentor, I understand that if selected, there is an interview process that follows this Application. I also understand that in order for me to participate in Peer Mentor Program, I must commit to a consequtive 3 months period.

Contact Us
Tara Mohamed, CCLS
732-258-7412
tmohamed@childrens-specialized.org
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