Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Email* Birthday* MM DD YYYY Age*School Name*Year In School*9th10th11th12thCollegeHave you ever been convicted of a crime?*YesNoIf yes to above question, please explain.*Please list any food allergies or dietary restrictions and severity.How did you hear about Teen Lifeline?*Name of Parent/Guardian*Email of Parent/Guardian* Person to notify in case of emergency*Relationship to you?*Phone Number*Address* Street Address City State / Province / Region ZIP / Postal Code Do you have available time to be a peer counselor?*YesNoBriefly list your hobbies or interests?*List any afterschool commitments or responsibilities you have (work, family, sports, clubs, etc.)*Briefly explain your interest or motivation in becoming a peer counselor.*What problems are teens facing today? How can Teen Lifeline help?*Can you realistically make a commitment to Teen Lifeline?*YesNoHave you had any experience with counseling before? Please describe.*How would you respond to a 15 year old girl who was having a problem with her boyfriend? Lately he doesn't seem to be interested in her, she feels shut out, alone and confused. She doesn't know what to do.*What is the role of a peer counselor?*CAPTCHA