Empower SCI Montana: Peer Mentor Application
Application as a Peer Mentor for the one-week residential program at the University of Montana at Missoula

Instructions:

**Montana**
Please complete and submit this form by February 28.
Notification of acceptance: May 1.

MT Staff Training: May 30 and 31, 2020
MT Program Dates: May 31 to June 6, 2020

Note: if you require >3 hours of personal care assistance, please arrange caregivers to provide your personal care assistant 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: Montana 05/31/2020, or New York 07/12/2020. Example: "20".
Your answer
Are you also interested in applying to volunteer at the New York program? *
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