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

Instructions:

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

NY Staff Training: July 11 and 12, 2020
NY Program Dates: July 12 to 25, 2020

Note: if you require >3 hours of personal care assistance, please arrange caregivers to provide your personal care. Empower SCI will pay for the room and board for both peer mentor and one personal care assistant.

Consider listing your "personal" email address here instead of a school or business account. Because of our volume of applicants, responses to school and business based emails are occasionally flagged as spam in our responses.
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
What is your T-Shirt Size? *
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: New York 07/12/2020. Example: "20".
Your answer
Are you also interested in applying to volunteer at the Montana program? *
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