Empower SCI Stony Brook: Peer Mentor Application
Application as a Peer Mentor for the two week residential program at Stony Brook University

Please complete and submit this form by May 1.
Notification of acceptance: June 1.

Staff Training: July 13 and 14, 2019
Program Dates: July 14 to 27, 2019

Email address *
Personal Information
Last Name *
Your answer
First Name *
Your answer
Telephone Number *
Please include an area code
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Emergency Contact *
Who can we call in the case of an emergency?
Your answer
Emergency Contact Telephone Number *
Your answer
What age will you be at the start of the program? *
Please enter the whole number age (years) you will have attained by program start date: 07/14/2019. Example: "20".
Your answer
What is your T-Shirt Size? *
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