*First Name *Last Name *Address *City *State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming *Zip *Home Phone Cell Phone *Email *Age Gender *Gender Choose not to disclose Female Male Other Transgender Female / Male-to-Female Transgender Male / Female-to-Male *Type of Disability *Date of onset of Disability *Educational Level *Educational Level Bachelors College (enrolled) Doctorate High School (9, 10, 11, 12) Masters Work Experience Hobbies/Interests/Clubs Do you have any previous Group or Leadership experience? YesNo If yes, please explain Reference Medical (Rehab Physician or Therapist)Work or School Personal *Name of Reference *Phone # of Reference *Relationship to Reference Please select day(s) of Availability MondayTuesdayWednesday ThursdayFriday *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 consecutive 3 months period. Yes Please confirm security question above